[exam findings]
[consultation]
[MedRec]
[chemotherapy]
[note]
Bortezomib (Velcade) plus cyclophosphamide and dexamethasone (VCD or CyBorD) for multiple myeloma 2023-04-24 https://www.uptodate.com/contents/image?topicKey=ONC%2F85687§ionRank=1&imageKey=ONC%2F50061
Cycle length: 28 days.
Regimen
Pretreatment considerations:
Monitoring parameters:
Suggested dose modifications for toxicity:
Treatment of Clostridioides difficile infection (CDI) in adults 2023-05-17 https://www.uptodate.com/contents/image?topicKey=ID%2F2698&imageKey=ID%2F53273
On 2023-05-14, the patient’s WBC was 7.37K/uL, creatinine was 1.01mg/dL, and stool occult blood was 2+. Stool culture obtained on 2023-05-15 was negative for Clostridioides difficile toxin A/B but positive for glutamate dehydrogenase (GDH). The patient had 9 and 8 bowel movements on 2023-05-15 and 2023-05-16, respectively. Therefore, the prescription of oral vancomycin at a dose of 125 mg 4 times daily is appropriate and unproblematic.
Now that the pathogen has been identified, the previously prescribed and currently active medication, Metrozole (metronidazole) 500mg PO Q8H, could potentially be discontinued, assuming there are no hypotension or shock, ileus, megacolon and/or other ongoing infectious conditions.
According to the HIS5 database, there have been no other culture reports on Clostridioides Difficile Infection (CDI) in the past 6 months. In the event of a recurrent infection, a tapered and pulsed regimen of vancomycin could be considered. Here is a possible schedule:
[assessment]
The patient has been diagnosed with Multiple Myeloma (MM) and was started on VCd regimen on 2023-01-03. All of the patient’s medications listed in PharmaCloud were prescribed by our hospital. No medication reconciliation issues were identified.
After starting the VCd regimen, there was a decrease in the B2 microglobulin level. However, the most recent reading indicates that the level has nearly doubled from the previous low in approximately 1.5 months.
Currently, there is no evidence that the patient is developing thrombocytopenia, peripheral neuropathy or neuropathic pain.
[exam findings]
[present illness] - 2023-02-23 admission note
[past history]
[allergy]
[family history]
[exam findings]
[MedRec]
[consultation]
[surigcal operation]
[radiotherapy]
[chemotherapy]
2023-04-25 - oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 750mg NS 250mL 2hr + fluorouracil 400mg/m2 750mg NS 100mL 10min + fluorouracil 2400mg/m2 4500mg NS 500mL 46hr (FOLFOX)
2023-03-27 - fluorouracil 225mg/m2 430mg NS 100mL 10min D1-4 (CCRT)
2023-02-23 - fluorouracil 225mg/m2 430mg NS 100mL 10min D1, 2, 5, 7 (excluding weekend and 2/28 holiday) (CCRT)
According to the PharmaCloud database, all of the patient’s recent medications have been prescribed by our hospital, and no issues with medication reconciliation have been detected.
On 2023-05-15, the patient’s WBC count was observed to be 1.89K/uL, indicating leukopenia. This was first noted in the HIS5 system 3 weeks after the last administration of FOLFOX on 2023-04-25. When this event became known, Granocyte (lenograstim) was administered for two consecutive days. The nadir may occur later than expected, or blood cell monitoring should be more frequent.
This patient experienced hand-foot syndrome following the second dose of concurrent chemotherapy with 5-FU in late March 2023. The patient is currently undergoing FOLFOX treatment. If hand-foot syndrome reoccurs, it may be advisable to omit the 5-FU bolus.
The patient has underlying kidney concerns, and the NSAID Celebrex (celecoxib) is currently prescribed as needed. If the primary purpose of using celecoxib is for pain management, considering an alternative like acetaminophen could be less harmful to the kidneys.
[assessment]
{malignant neoplasm of unspecified site of left female breast, cT4aN3M1, stage IV}
[exam findings]
[surgical operation]
[chemoimmunotherapy]
[blood WBC]
[G-CSF]
[tube feeding]
As of 2023-05-12, the patient’s serum potassium level was measured at 3.2 mmol/L. Currently, Const-K is the only oral potassium supplement available in this hospital. If intravenous potassium supplementation is not the preferred method, it’s recommended to crush the Const-K tablet into small enough particles to pass through the feeding tube, and administer the supplement with sufficient water. It’s preferable to give this medication with meals due to its original extended-release design.
[past history]
Heart:(-)
Chest:(-)
Liver:(-)
Kidney:(-)
H/T:(-)
DM:(-)
Surgical:
Menstrual history: G2P2, menopause at age of 48
[allergy]
[family history]
[lab data]
2023-01-11 Anti-HBc Nonreactive
2023-01-11 Anti-HBc-Value 0.89 S/CO
2023-01-11 Anti-HBs 329.77 mIU/mL
2023-01-11 Anti-HCV Nonreactive
2023-01-11 Anti-HCV Value 0.07 S/CO
2023-01-11 HBsAg Nonreactive
2023-01-11 HBsAg (Value) 0.31 S/CO
[exam findings]
[consultation]
[MedRec]
[surgical operation]
[chemotherapy]
[assessment]
The PharmaCloud database reveals that the patient’s recent drugs have all been prescribed at our hospital. Currently, there are no issues detected with medication reconciliation in the active prescription.
The patient’s anemia, as evidenced by a decrease in hemoglobin level from 10.2 g/dL on 2023-05-02 to 8.1 g/dL on 2023-05-09, is currently being treated with a transfusion of 2 units of packed red blood cells (P-RBC), scheduled for 2023-05-11, as indicated.
The patient’s lab data reveals a decreasing trend in serum albumin levels, raising the possibility of a protein-losing gastroenteropathy. However, current records do not indicate the presence of edema, ascites or pleural and pericardial effusions. Furthermore, liver and kidney function appear to be within or not far from normal ranges based on the lab data, suggesting that heavy proteinuria or impaired protein synthesis due to liver disease are less likely causes. It is recommended to encourage the patient to pay more attention to nutritional supplementation to prevent malnutrition.
Intestinal leakage of plasma proteins occurs via one of the following mechanisms:
The CT scan on 2023-04-22 revealed recurrent tumors in the pelvic cavity measuring 4.7cm and 7.9cm, respectively. These tumors have invaded adjacent structures, causing right hydronephrosis and hydroureter, and lymph nodes are also evident in the retroperitoneum. These findings might be related to the observed clinical phenomena mentioned above?
[assessment]
[exam findings]
[MedRec]
[consultation]
[chemotherapy]
Please be aware that the patient’s renal function has been declining over the past three days. At present, there’s no need for a dose adjustment, but it’s crucial to continue monitoring closely.
Lab data has shown signs of recovery in the patient’s WBC count. However, the PLT count continues to hover at relatively low levels, never reaching 100K/uL.
Indications for platelet transfusion include actively bleeding patients with thrombocytopenia who should receive immediate platelet transfusion to maintain platelet counts above 50K/uL in most bleeding situations, including disseminated intravascular coagulation (DIC), and above 100K/uL in central nervous system bleeding.
Unfortunately, there are no perfect tests to predict spontaneous bleeding. Studies in patients with thrombocytopenia suggest that spontaneous bleeding can occur even with platelet counts above 50K/uL. However, bleeding is much more likely when the platelet count falls below 5K/uL. For individuals with platelet counts between 5K and 50K/uL, clinical observations may be useful in deciding whether to transfuse platelets.
[diagnosis] - 2023-05-08 admission note
[MedRec]
[radiotherapy]
[chemotherapy]
[assessment]
[diagnosis] - 2023-03-23 admission note
[past history]
[allergy]
[family history]
[exam findings]
[consultation]
[surgical operation]
[radiotherapy]
[chemotherapy]
{not completed}
[MedRec]
[chemotherapy]
[assessment]
[MedRec]
[chemotherapy]
[assessment]
[lab data]
[exam findings]
[consultation]
[MedRec]
[radiotherapy]
[chemotherapy]
[tube feeding]
Nexium (esomeprazole) should not be crushed. Instead, it should be dissolved in sufficient drinking water before tube feeding.
[tube feeding]
[tube feeding]
[diagnosis] - 2023-05-07 admission note
[present illness]
[past history] - 2023-05-07 admission note
[family history]
[lab data]
[exam findings]
[consultation]
[MedRec]
[surgical operation]
[radiotherapy]
[chemoimmunotherapy]
From 2022-11-21 to 2023-01-09, the patient was treated with Avastin plus FOLFOX for his K-RAS-mutated sigmoid colon adenocarcinoma. However, a CT scan on 2022-12-02 showed progressive disease with multiple liver and lung metastases, as well as metastatic nodes in the mesentery, left common iliac chain, sigmoid mesocolon, and perirectal space. As a result, the regimen was changed to Avastin plus FOLFIRI on 2023-01-27. Due to dizziness and headache experienced during chemotherapy on 2023-03-01, the fluorouracil dose was reduced by half starting on 2023-03-21.
After the new regimen was applied, the tumor marker CEA has remained relatively unchanged; however, the readings are approximately twice as high as they were before.
The Covid-19 fast screen was positive on 2023-04-24, but the patient has since recovered. Vital signs are currently stable. CT and CXR revealed lung mets with multiple nodular opacities in both lungs, which do not significantly impair the patient’s respiratory function yet.
The underlying conditions are currently being managed with appropriate medications: anemia is treated with Foliromin (ferrous sodium citrate), toe numbness is treated with Kentamin (B1, B6, B12), right upper quadrant abdominal and rib area pain is treated with Tramacet (tramadol, acetaminophen) and Neurontin (gabapentin), respiratory symptoms are treated with Romicon-A (dextromethorphan, cresolsulfonate, lysozyme), oral candidiasis is treated with Mycostatin (nystatin), and intermittent diarrhea is managed with loperamide and Smecta (dioctahedral smectite) as needed (PRN).
[drug interaction]
The ability of oral iron preparations to reduce the absorption of oral quinolones is well established and has been demonstrated in numerous pharmacokinetic studies. Various oral iron preparations have been reported to reduce quinolone AUCs by the following percentages: ciprofloxacin (33% to 70%), levofloxacin (19%), lomefloxacin (14%), moxifloxacin (61%), norfloxacin (51% to 73%), ofloxacin (25%), and sparfloxacin (28%). The maximum serum concentrations of oral quinolones were reduced by the following percentages: ciprofloxacin (46% to 75%), levofloxacin (45%), lomefloxacin (28%), moxifloxacin (41%), norfloxacin (75% to 82%), ofloxacin (36%), and sparfloxacin (46%). It is recommended to administer oral quinolones at least several hours before (4 h for moxifloxacin and sparfloxacin, 2 h for others) or after (8 h for moxifloxacin, 6 h for ciprofloxacin and delafloxacin, 4 h for lomefloxacin, 3 h for gemifloxacin, 2 h for enoxacin, levofloxacin, norfloxacin, ofloxacin, pefloxacin, or nalidixic acid) oral iron preparations.
Due to the fact that Cravit (levofloxacin) and Foliromin (ferrous sodium citrate) were prescribed as QDAC and BID, respectively. To maintain Cravit’s effectiveness, Foliromin might be moved to QL and QN.
Please monitor for diminished effects of the quinolone if dose separation cannot be achieved.
[diagnosis] - 2023-04-26 admision note
[past history] - 2023-04-26 admision note
[allergy]
[family history]
[exam findings]
[lab data]
[consultation]
[MedRec]
On 2023-05-08 at 06:05, the patient’s SpO2 dropped to 69%, accompanied by an increased heart rate of 100 bpm. This indicates possible respiratory distress or compromised oxygenation, and an O2 mask is placed appropriately.
If the patient continues to experience hemoptysis, inhaled tranexamic acid could be considered as a potential treatment option to reduce bleeding. This antifibrinolytic agent has been shown to effectively control bleeding and may provide relief to the patient.
[exam findings]
[consultation]
[surgical operation]
2022-02-11 MWA, Microwave ablation
2021-09-27 VATS, decortication
2021-03-29 VATS, LUL and LLL wedges resection for metastasectomy + pneumolysis
2021-09-16 RFA, Radiofrequency Ablation
2021-08-19 RFA, Radiofrequency Ablation
2020-07-01 3D VATS RUL, RML and RLL wedge resections + LND. decortication
2018-03-29 laparoscopic lower anterior resection w/ TaTME and S3, S8 subsegmentectomy + S5 cyst unroofing (Taipei Veterans General Hospital)
[radiotherapy]
[chemoimmunotherapy]
[note]
FOLFOXIRI chemotherapy for metastatic colorectal cancer 2023-04-25 https://www.uptodate.com/contents/image?topicKey=ONC%2F2503&imageKey=ONC%2F70559
Cycle length: 14 days.
Regimen
Pretreatment considerations:
Monitoring parameters:
Suggested dose modifications for toxicity (The specific dose alteration parameters for the FOLFOXIRI regimen in colorectal cancer patients were not published in the original phase III trial. The following suggestions are based upon dose reductions used in a trial using a comparable regimen (FOLFIRINOX) for advanced pancreatic cancer.)
[tube feeding]
{not completed}
[MedRec]
[exam findings]
[assessment - not posted]
[exam findings]
[MedRec]
[chemoimmunotherapy]
[assessment]
{not completed}
[MedRec]
[surgical operation]
[medication]
2023-03-15 ~ 2023-03-29 - UFT (tegafur 100mg, uracil 224mg) 2# BID
2022-02-08 ~ 2022-04-25 - TS-1 (tegafur, gimeracil, oteracil) 2# BID
2021-09-09 ~ 2021-10-15 - Xeloda (capecitabine 500mg) 2# BID
B-Red (hydroxocobalamin 1mg)
[diagnosis] - 2023-03-22 SOAP
[past history]
[allergy]
[family history]
[exam findings]
[MedRec]
[chemotherapy]
[note]
hyperbilirubinemia - ref: 2023-05-05 UpToDate
CA199, CEA - ref: 2023-05-05 ChatGPT
Nab-paclitaxel and gemcitabine treatment was first initiated on 2023-03-27 and is currently ongoing. The 3rd dose was administered on 2023-04-24 with a 20% reduction in dosage due to dizziness, nausea, and vomiting. The patient also experienced conscious disturbance and abdominal fullness, which led to ascites tapping on 2023-05-02.
After receiving 3 doses of the regimen, the patient’s tumor marker CA199 remains relatively unchanged, while there is a significant increase in CEA levels.
The TPR panel indicated no bowel movement on 2023-05-03 and 2023-05-04. It is suggested to assess whether the patient has developed constipation, as bisacodyl is prescribed as needed (PRN) for this issue.
[tube feeding]
As of 2023-05-01, the patient’s serum potassium level has returned to the normal range of 3.5 mmol/L. However, the current prescription for Const-K will expire on 2023-05-04, and it may be worth considering discontinuing this medication. It should be noted that the potassium content of fruits is relatively low (for example, about 2.2 mEq/inch or 0.9 mEq/cm in bananas), meaning that it would take about two to three bananas to provide 40 mEq. Const-K is an extended-release formulation containing 10 mEq/tab, which is less potassium than is found in one banana. If injectable potassium supplementation is not preferred (Const-K remains the only oral potassium supplement available today), please crush the tablet into particles and administer it with water.
For patients who have difficulty swallowing Protase (pancrelipase) capsules, the capsule can be opened and the enteric-coated granules can be released into a small amount of liquid food with a pH not exceeding 5.5. Tube feed the drug particles with drinking water or juice to ensure complete ingestion.
As for Megejohn (megestrol acetate), since our hospital has Megest (megestrol 40mg/mL, 120mL/bot) in stock, it is suggested to switch Megejohn to the Megest oral suspension.
[exam findings]
[MedRec]
[radiotherapy]
[chemotherapy]
2023-05-04 - irinotecan 180mg/m2 290mg D5W 250mL 90min + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2800mg/m2 4555mg NS 250mL 46hr (FOLFIRI)
2023-04-07 (FOLFIRI)
2023-03-22 (FOLFIRI)
2023-03-08 (FOLFIRI)
2023-02-22 (FOLFIRI)
2022-02-23 - oxaliplatin 85mg/m2 130mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 3800mg NS 500mL 46hr (FOLFOX)
2022-02-09 (FOLFOX)
2022-01-26 (FOLFOX)
2022-01-12 (FOLFOX)
2021-12-29 (FOLFOX)
2021-12-15 (FOLFOX)
2021-12-01 (FOLFOX)
2021-11-17 (FOLFOX)
2021-11-03 (FOLFOX)
2021-10-20 (FOLFOX)
2021-10-01 (FOLFOX)
2021-09-09 (FOLFOX)
[assessment]
No medication reconciliation issues have been identified for this patient.
The patient appears to be tolerating the current regimen well, and his labs are mostly within normal ranges, with the exception of slightly elevated liver function tests and BUN.
[allergy]
[family history]
[exam findings]
[consultation]
[MedRec]
[exam findings]
[assessment]
Hyperleukocytosis (leukostasis) was confirmed by laboratory tests, and the patient has been treated with Hydrea (hydroxyurea 500mg) 2# TID since 2023-05-03, which has helped to control the high WBC count.
Leukostasis can be diagnosed when a biopsy of affected tissue shows white cell clots in the microvasculature (2023-05-02 CT: suspected splenic infarct). Please be aware of possible clinical signs of leukostasis, such as
Feburic (febuxostat) is used as prophylaxis for potential tumor lysis syndrome. Lab data show that elevated serum uric acid levels have returned to normal following administration of the drug.
Caution should be exercised when using intravenous contrast at a time when renal function may be compromised by leukostasis or tumor lysis syndrome and dehydration. (2023-05-04 BUN 29mg/dL, Cre 1.10mg/dL, eGFR 70.75, normal values in K. The patient is currently hydrated with NS 500mL BID. No apparent renal insufficiency at this time).
[lab data]
[exam findings]
[MedRec]
[note]
FOLFIRINOX chemotherapy for metastatic pancreatic cancer 2023-05-04 https://www.uptodate.com/contents/image?topicKey=ONC%2F2475&imageKey=ONC%2F79571
[chemotherapy]
[assessment]
This is the first time the patient has received FOLFIRINOX chemotherapy for his pancreatic cancer, with a reduced dose of irinotecan (180mg/m2 reduced to 120mg/m2) and oxaliplatin (85mg/m2 reduced to 65mg/m2). Thus far, no significant adverse reactions have been observed.
2023-05-03 Anti-HBc Reactive
2023-05-03 Anti-HBc-Value 8.55 S/CO
[diagnosis] - 2023-05-02 admission note
[exam findings]
[consultation]
[MedRec]
[surgical operation]
[chemoimmunotherapy]
[assessment]
The patient was diagnosed with gastric adenocarcinoma, pT4aN1M0 stage IIIA in July 2022. Total gastrectomy with lymphadenectomy was performed on 2022-09-05, followed by FOLFOX treatment starting on 2022-10-05.
A CT scan on 2022-11-28 showed liver metastases in progression, and a PET scan on 2022-12-26 revealed that the gastric cancer had progressed, with suspected regional lymph nodes and liver metastases, cTxN2M1, stage IVB. After receiving six doses of FOLFOX (with the last dose administered on 2022-12-23), the patient’s regimen was changed to FOLFIRI starting on 2023-01-12.
The patient was admitted to the hospital for his 6th dose of FOLFIRI (trastuzumab was added to the regimen since 2023-04-07, making this the 2nd dose). The patient tolerates the regimen well, and no significant adverse reactions have been observed.
After partial or total gastrectomy, the availability of gastric acid and intrinsic factor, both essential for vitamin B12 absorption, is reduced or eliminated. As a result, individuals who have undergone partial or total gastrectomy would benefit from supplementing their diet with oral vitamin B12 or receiving intramuscular or subcutaneous injections of vitamin B12. B-Red (hydroxocobalamin) is appropriately administered as a daily supplement for this patient.
The patient’s underlying condition of chronic viral hepatitis B is appropriately treated with Baraclude (entecavir).
A review of the PharmaCloud database reveals that all of the patient’s most recent medications were prescribed at our hospital, and no medication reconciliation issues were identified.
The patient was proved with gastric adenocarcinoma, pT4aN1M0 stage IIIA in July 2022. Total gastrectomy with lymphadenectomy was performed on 2022-09-05 then FOLFOX was applied since 2022-10-05.
2022-11-28 CT showed liver mets in progression and 2022-12-26 PET showed the gastric cancer progressed with suspected regional lymph nodes and liver mets, cTxN2M1, stage IVB. After administration of 6 times of FOLFOX (last dose on 2022-12-23), then the regimen changed to FOLFIRI since 2023-01-12.
The patient admitted this hospitalization for his 6th dose of FOLFIRI (trastuzumab was added to the regimen since 2023-04-07, this time the 2nd dose). The patient tolerates the regimen well and no obvious adverse reaction is found.
The PharmaCloud database shows that all of the patient’s most recent medications were prescribed at our hospital, and no medication reconciliation issues were identified.
[diagnosis]
[past history]
[family history]
[exam findings]
[chemotherapy]
On 2022-10-07, 2023-01-05, and 2023-04-29, CT scans demonstrated disease progression, with the most recent scan also revealing possible liver metastases. This information highlights the need for close monitoring and potentially re-evaluating the patient’s treatment plan.
The patient’s renal function improved according to the most recent lab values.
If the initial consideration for reducing the dose of topotecan was due to the patient’s inadequate renal function, this reason becomes less important. However, the patient also experienced leukopenia and thrombocytopenia after the standard dose of 1.5 mg/m2 topotecan in January 2023. The full standard dose may potentially lead to episodes of leukopenia and/or thrombocytopenia. A moderate titration to 0.9 or 1.0 mg/m2 from 0.75mg/m2 could be considered as a feasible option to balance treatment efficacy and side effect profile if the same regimen is intended to be continued.
This patient has a tendency to develop leukopenia and/or thrombocytopenia after receiving the normal dose of 1.5mg/m2 topotecan. However, after the dose was reduced to 0.75mg/m2, no further high-grade adverse reactions were observed.
2023-03-02 WBC 5.87 x10^3/uL
2023-02-23 WBC 12.24 x10^3/uL
2023-02-16 WBC 3.07 x10^3/uL
2023-02-13 WBC 4.44 x10^3/uL
2023-02-09 WBC 22.96 x10^3/uL
2023-02-06 WBC 2.70 x10^3/uL
2023-02-03 WBC 2.09 x10^3/uL
2023-02-01 WBC 2.32 x10^3/uL
2023-01-30 WBC 1.66 x10^3/uL
2023-01-27 WBC 0.71 x10^3/uL
2023-01-26 WBC 0.70 x10^3/uL
2023-01-22 WBC 2.41 x10^3/uL
2023-01-16 WBC 5.05 x10^3/uL
2023-03-02 PLT 234 x10^3/uL
2023-02-23 PLT 109 x10^3/uL
2023-02-16 PLT 275 x10^3/uL
2023-02-13 PLT 308 x10^3/uL
2023-02-09 PLT 270 x10^3/uL
2023-02-06 PLT 123 x10^3/uL
2023-02-03 PLT 65 x10^3/uL
2023-02-01 PLT 47 x10^3/uL
2023-01-30 PLT 50 x10^3/uL
2023-01-27 PLT 154 x10^3/uL
2023-01-26 PLT 38 x10^3/uL
2023-01-22 PLT 155 x10^3/uL
2023-01-16 PLT 312 x10^3/uL
S2021-11516A9 (renal pelvic cancer) 2023-01-27 PD-L1 IHC lab results:
PD-L1 expression is not high, suggesting that certain PD-L1 targeted drugs are less likely to be effective against the tumor.
In light of the patient’s diarrhea episodes last month, please keep an eye on her bowel movements. Topotecan is associated with nausea (grade 3/4 8-10%), diarrhea (grade 3/4 6%), and vomiting (grade 3/4 10%). Since the administration days and daily dose of topotecan have been reduced (1.5mg/m2 -> 0.75m2/m2; 5 days -> 3 days), the adverse reaction should be mitigated. As well, Smecta (dioctahedral smectite) 3mg PO PRNTIDAC has been prescribed.
[diagnosis] - 2023-04-27 admission note
[exam findings]
[consultation]
[MedRec]
[surgical operation]
[chemotherapy]
2023-04-21 - docetaxel 30mg/m2 38mg D5W 250mL 1hr + leucovorin 200mg/m2 250mg NS 250mL 2hr + fluorouracil 2000mg/m2 2515mg NS 500mL 24hr + [paclitaxel 20mg NS 1000mL + gentamicin 40mg + sodium bicarbonate 4200mg] IP 1hr (NIPS)
2023-02-14 - oxaliplatin 130mg/m2 150mg D5W 250mL 2hr + [paclitaxel 20mg NS 1000mL + gentamicin 40mg + sodium bicarbonate 2800mg] (with 2023-02-16 ~ 2023-03-14 oral capecitabine)
2023-01-12 - [oxaliplatin 400mg + paclitaxel 120mg + D5W 2500mL] IP 90min
Xeloda (capecitabine 500mg) KXEL)01
[assessment]
Significant weight loss has been observed in the patient, from 43.5kg on 2023-01-06 to 33.3kg on 2023-04-27. Megestrol has been prescribed intermittently between late Dec 2022 and late Feb 2023. If the patient can still tolerate oral intake and there are no contraindications, it may be beneficial to consider adding megestrol back into the patient’s treatment plan to help increase appetite and promote weight gain.
Additionally, providing nutritional support and guidance, including a consultation with a dietician, may further assist in addressing the patient’s weight loss.
The patient has had 7 episodes of diarrhea since 2023-04-26, as noted in the admission record. It is recommended that the number of bowel movements be included in the TPR panel along with the I/O data. If the symptom persists, the addition of loperamide may be beneficial in the management of diarrhea.
Both docetaxel and fluorouracil are associated with diarrhea as a side effect. If diarrhea is suspected to be more related to fluorouracil (2000mg/m2 D1), reducing the dose of fluorouracil (70~80% of the intended dose) at the next treatment may be an option to consider.
[exam findings]
[MedRec]
[chemoimmunotherapy]
[Trimethoprim/Sulfamethoxazole (TMP/SMX) dosing]
Trimethoprim/sulfamethoxazole(TMP/SMX) for patients with moderate to severe Pneumocystis pneumonia infection: IV 15 to 20 mg/kg/day (TMP component) in 3 or 4 divided doses; may switch to oral therapy after clinical improvement.
As recent lab results revealed no abnormalities in the liver and kidney functions, it is less likely that dosage adjustments will be needed.
Patients with moderate or severe infection (PaO2 <70 mm Hg at room air or alveolar-arterial oxygen gradient >= 35 mm Hg) should receive adjunctive glucocorticoids.
{not completed}
[exam findings] (not completed)
[consultation]
[assessment]
AKuriT-4 (RIF 150mg + INH 75mg + PZA 400mg + EMB 275mg) 3# PO QDAC is administered according to the patient’s bone tuberculosis.
It is important to note that the patient is currently taking multiple NSAIDs (Laston (ketorolac) ST, Celebrex (celecoxib) QD, naproxen PRNQ8H). Concomitant use of multiple NSAIDs is not recommended due to the increased risk of side effects such as bleeding and kidney damage. Please monitor the patient closely for signs of bleeding or changes in kidney function and consider adjusting her medication regimen if necessary.
[diagnosis] - 2023-03-29 admission note
[past history] - 2023-03-06 admission note
[allergy]
[family history]
[exam findings]
[consultation]
[surgical operation]
[chemotherapy]
2023-04-26 lab results showed low serum Na (133 mmol/L), K (3.4 mmol/L), Mg (1.4 mg/dL), and albumin (3.3 g/dL). These electrolyte imbalances are currently being addressed with appropriate supplementation. With the exception of mild anemia, the patient’s blood cell counts are within normal limits and do not represent a contraindication to the planned chemotherapy.
The PharmaCloud database shows that all of the patient’s most recent medications were prescribed at our hospital, and no medication reconciliation issues were identified.
Laboratory data on 2023-03-29 showed normal liver/kidney function, however, cation electrolytes and HGB were slightly decreased, which would not contraindicate the planned chemotherapy.
Ascites cytology on 2023-03-08, 2023-03-07, 2023-02-20, 2023-02-17 showed no evidence of positive results.
No medication reconciliation issue identified.
{not completed}
[exam findings]
[surgical operation]
[chemotherapy]
Medication
[assessment]
[past history] - 2023-04-20 admission note
Hypertension for 10 years with regular medication control.
DM with triopathy for 10+ years with regular OHA, insulin control.
Asthma: Asthma since young with regular OPD f/u.
Operation history: Appendectomy 10 yrs ago.
Denied history of Hypertension, DM, asthma
Denied any operation, accident and other medical Hx.
[allergy]
[family history]
[exam findings]
[consultation]
[lab data]
[MedRec]
[assessment]
The patient was diagnosed with rectosigmoid cancer and underwent sigmoidectomy followed by treatment with the FOLFOX regimen in 2020. However, the patient experienced progressive disease. Laparoscopic plevic LND was performed in March 2022, and the patient was subsequently treated with the A-FOLFIRI regimen, but again experienced PD. This time, the patient was admitted to receive the planned FOLFOXIRI regimen.
Flumarin (flomoxef sodium) has been administered since 2023-04-23 to address the elevated sediment WBC and leukocyte esterase in the patient’s urine without issues.
The patient’s platelet count (PLT) has been decreasing over the past three years, with levels not exceeding 100K/uL in 2023. This should be carefully monitored, as it may suggest the presence of undiagnosed underlying conditions that require further evaluation and management.
[diagnosis] - 2023-04-25 admission note
[past history] - 2023-04-25 admission note
DM, HTN, CHF, COPD, Hyperlipidemia, Asthma
[allergy]
[family history]
no hypertension, diabetes mellitus, cancer history
[exam finding]
[consultation]
[MedRec]
[chemoimmunotherapy]
[note]
There is no medication reconciliation issue for the current active formulary, which includes medications prescribed by our cardiologist, pulmonologist, and metabolic specialist.
The patient’s underlying conditions of hypertension (HTN) and type 2 diabetes mellitus (T2DM) are not well controlled during this hospitalization. Blood pressure readings show systolic values between 170 and 184 mmHg, and HbA1c levels have been consistently above 8% for the past 4 months. Serum glucose was recorded as 231mg/dL on the evening of 2023-04-25 and as 158mg/dL on the morning of 2023-04-26. Addition of antihypertensive and/or hypoglycemic agents may be considered if symptoms persist.
[exam findings] (not completed)
[consultation]
[chemotherapy]
2022-09-27 - doxorubicin 60mg/m2 85mg NS 100mL 10min
2022-08-30
2022-08-01
2022-07-01
2022-05-31
2022-01-03 - cisplatin 100mg/m2 150mg NS 500mL 4hr + fluorouracil 1000mg/m2 1550mg NS 500mL 21hr
2021-11-12 - NS 500mL (before cisplatin) + cisplatin 30mg/m2 40mg NS 500mL 2hr + NS 500mL (after cisplatin) (CCRT)
2021-11-05
2021-10-29
2021-05-11
2021-05-04
2021-04-28
2020-11-03
2020-10-27
2020-10-20
[assessment]
On 2023-04-03, a PET scan revealed multiple glucose hypermetabolic lesions in the right supra-renal region, right paraaortic space, bilateral common iliac chains, and soft tissue in the right lower quadrant (RLQ) of the abdomen. These lesions could indicate metastatic disease progression or even another primary malignancy. A CT-guided biopsy of the soft tissue mass in the right lower quadrant of the abdomen is scheduled for 2023-04-25 at 11:00 AM to determine the nature of these lesions.
2023-04-24 eGFR 46. OxyNorm (oxycodone) - CrCl 30 to <60 mL/minute: Immediate release, Oral: Initial: Administer 50% to 75% of usual dose no more frequently than every 6 hours. Use with caution; titrate gradually based on patient response and adverse effects.
[exam findings]
[consultation]
[MedRec]
[diagnosis] - 2023-04-22 discharge note
[exam findings]
2023-03-11 Anoscopy
2023-02-09 2D transthoracic echocardiography
2022-12-22 Nasopharyngoscopy
2022-11-24 2D transthoracic echocardiography
2022-11-17 SONO - abdomen
2022-10-26 PET scan
2022-10-18 Patho - breast mastectomy with regional lymph nodes
2022-10-18 Frozen Section
2022-10-17 Flow Volume Loop
2022-10-07 Patho - breast biopsy (no need margin)
2022-10-07 SONO - breast
2022-10-07 Mammography
2022-08-25 SONO - abdomen
2022-08-11 Nasopharyngoscopy
2022-06-30 ENT Hearing Test
2022-06-08 Neurosonology
2022-06-02 SONO - abdomen
……
……
2017-05-26 Surgical pathology Level VI
2017-05-25 PET scan
2017-05-22 Gynecologic ultrasonography
2017-05-16 Surgical pathology Level IV
2017-05-16 SONO - breast
[consultation]
[MedRec]
[surgical operation]
[radiotherapy]
[chemotherapy]
2023-04-21 - docetaxel 75mg/m2 110mg NS 250mL 1hr
2023-03-31 - docetaxel 75mg/m2 111mg NS 250mL 1hr
2023-03-10 - docetaxel 75mg/m2 108mg NS 250mL 1hr
2023-03-02 - docetaxel DC (due to WBC 1.57K/uL)
2023-02-09 - liposome doxorubicin 30mg/m2 40mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 866mg NS 500mL 1hr
2023-01-18 - liposome doxorubicin 30mg/m2 40mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 860mg NS 500mL 1hr
2022-12-21 - liposome doxorubicin 35mg/m2 58mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 988mg NS 500mL 1hr (2023-01-11 WBC 1.67K/uL)
2022-11-29 - liposome doxorubicin 35mg/m2 50mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 864mg NS 500mL 1hr
Femara (letrozole) KFEMA01
Granocyte (lenograstim) CGRAN01
Foliromin (ferrous sodium citrate) KFOLIR01
The patient’s HGB levels show a marked downward trend, even though there is no record of blood transfusion. With recent MCV and MCH levels both above the normal range, this macrocytic anemia is less likely to be caused by iron deficiency. The addition of oral Kentamine (vitamin B1, B6, B12) may be helpful.
The development of anemia during chemotherapy suggests that the patient’s HGB levels are not fully recovered at the current dosage, interval, and frequency of the treatment regimen. In cases of severe chemotherapy-induced anemia, blood transfusion is recommended. Another potential option could be to reduce docetaxel from 75mg/m2 to 65mg/m2.
If the patient refuses a blood transfusion, a less optimal alternative may be the use of erythropoiesis-stimulating agents (ESAs). However, it is important to note that ESAs have been associated with shorter overall survival and/or increased risk of tumor progression or recurrence in clinical trials involving patients with breast, non-small cell lung, head and neck, lymphoid, and cervical cancers. To minimize these risks, as well as the risk of serious cardiovascular and thromboembolic reactions, the lowest effective dose should be used to avoid red blood cell transfusions. ESAs should only be used for anemia resulting from myelosuppressive chemotherapy and are not indicated for patients receiving myelosuppressive chemotherapy when the expected outcome is cure. It is also recommended that ESAs be discontinued after completion of chemotherapy.
On 2022-10-28, the multidisciplinary cancer team held a meeting and decided on the following treatment plan for the patient: TC chemotherapy every three weeks for a total of 4 cycles, followed by a CDK4/6 inhibitor (patient self-paid), radiotherapy, and 5 years of hormone therapy.
The patient received 4 cycles of AC (liposome doxorubicin plus cyclophosphamide) on 2022-11-29, 2022-12-21, 2023-01-18, and 2023-02-09. On 2023-01-11, leukopenia occurred with a WBC count of 1.67K/uL, leading to a reduction in liposome doxorubicin dosage from 35mg/m2 to 30mg/m2 for the last two cycles. On 2023-03-02, another leukopenia episode was observed with a WBC count of 1.57K/uL, causing the scheduled docetaxel on that day to be postponed.
The patient’s HGB and PLT levels are showing a obvious decline trend, despite no record of blood transfusion being available. This suggests that under the current dose, interval, and frequency of administration, the patient’s HGB and PLT levels are not able to fully recover.
When severe anemia caused by chemotherapy is present, blood transfusion is recommended. However, if the patient refuses to receive transfusion, a suboptimal option could be to use erythropoiesis-stimulating agents (ESAs). It is important to note that ESAs have been associated with a shortened overall survival and/or an increased risk of tumor progression or recurrence in clinical studies of patients with breast, non-small cell lung, head and neck, lymphoid, and cervical cancers. To decrease these risks, as well as the risk of serious cardiovascular and thromboembolic reactions, the lowest effective dose should be used to avoid RBC transfusions. ESAs should only be used for anemia from myelosuppressive chemotherapy and are not indicated for patients receiving myelosuppressive chemotherapy when the anticipated outcome is cure. It is also suggested to discontinue ESAs following the completion of a chemotherapy course.
[diagnosis] - 2023-03-22 admissiion note
[past history]
The patient had no systemic diseases
History of operation: NIL
Regular medications or herb: no
G2P2
menarche : 16y/o
menopause: 51y/o
Hormone therapy: (-)
Family history of breast cancar: NIL
[allergy]
[family history]
[exam findings]
[consultation]
[surgical operation]
[chemotherapy]
[note]
in-hospital “Prescription Collection of Chemotherapy for Breast Cancer” protocol (dated 2022-03-11)
{not completed}
[diagnosis] - 2023-04-21 discharge note
[exam findings]
[lab data]
2021-09-23 EGFR Sample No S21-11584
2021-09-23 EGFR G719X not detected
2021-09-23 EGFR Exon19 del not detected
2021-09-23 EGFR S768I not detected
2021-09-23 EGFR T790M not detected
2021-09-23 EGFR Exon20 ins not detected
2021-09-23 EGFR L858R detected
2021-09-23 EGFR L861Q not detected
[MedRec]
[medication]
[diagnosis] - 2023-04-13 admission note
[present illness] - 2023-04-13 admission note
[past history]
[allergy]
[family history]
1.There is no family history of cancer, hypertension, mental diseases or asthma. 2.No members of the family with diabetes.
[lab data]
2023-04-17 Anti-HCV Nonreactive
2023-04-17 Anti-HCV Value 0.10 S/CO
2023-04-17 Anti-HBc Reactive
2023-04-17 Anti-HBc-Value 4.11 S/CO
2023-04-17 Anti-HBs 774.10 mIU/mL
2023-04-17 HBsAg Nonreactive
2023-04-17 HBsAg (Value) 0.40 S/CO
[chemotherapy]
[assessment]
[exam findings]
[SOAP]
[assessment]
The patient should have been diagnosed with dyslipidemia and hypertension with heart failure, as he has regularly refilled prescriptions for rosuvastatin, valsartan, and spironolactone within the past 3 months, according to PharmaCloud. Additionally, a CT scan on 2023-04-03 revealed extensive 3-vessel coronary artery disease (3V-CAD), indicating significant atherosclerotic plaque in the LAD, LCX, and RCA.
If there are no contraindications, it is recommended to reintroduce these medications and consult a cardiologist to assess whether the patient requires aggressive medical management or revascularization procedures, such as coronary artery bypass graft surgery (CABG) or percutaneous coronary intervention (PCI angioplasty with stent placement).
[chief complaint] - 2023-04-17 admission note
[present illness] - 2023-04-17 admission note
The 57 y/o woman has history of hypertension. She had fall down in bus on 2022/11 and then fatigue, vertigo and right hip pain since 2023/01/07, so she bedridden for 3 months. Right breast tumor noted also 3 months. This time, she has dizziness and severe vertigo, so she was brought to our ED for help on 2023/04/17. Her right lower limbs MP down to 3 for 3 months. She denied fever, chills, vomit, SOB or hematuria. At ED, the brain CT showed 1. Mild cortical brain atrophy. 2. Left parietal skull osteolytic destruction, metastasis or less likely arachnoid granulation? 3. Chronic left mastoiditis. UTI noted from urinalysis. Under the impression of right breast tumor, vertigo, suspect spinal stenosis, so she was admitted on 2023/04/17.
[past history]
[allergy]
[family history]
[exam findings]
[SOAP]
[assessment]
[diagnosis] - 2023-04-12 admission note
[past history]
[family history]
[lab data]
[exam findings]
[surgical operation]
[chemotherapy]
[past history] - 2023-04-13 admission note
OB/GYN history:
[allergy]
[family history]
[exam findings]
[consultation]
[surgical operation]
[assessment]
[exam findings]
[consultation]
[surgical operation]
[chemotherapy]
[assessment]
{not completed}
[exam findings]
[consultation]
[chemotherapy]
UFT (tegafur 100mg + Uracil 224mg) KUFT01
[assessment]
[exam findings]
[chemotherapy]
[assessment]
The patient’s serum creatinine has been above 2 mg/dL since 2022Q4 and has not dropped below that level since. The eGFR has been consistently around 30 since 2023.
On 2023-04-13 the following lab results were obtained: HGB 5.1g/dL, Iron bound Fe 22ug/dL, UIBC 145ug/dL, TIBC 146ug/dL, AST 14U/L, and ALT 13U/L. On 2023-04-14, Ferritin was 545ng/mL and Transferrin was 124ng/mL. There is no evidence of iron deficiency or liver dysfunction. Anemia of chronic disease and/or anemia of inflammation might be possible, as well as nutritionally deficiency. The body weight of 36.5 kg recorded on the TPR panel on 2023-04-13 appears to be too low, which may be an erroneous entry.
[diagnosis] - 2022-11-25 admission note
[past history]
[allergy]
[family history]
[exam findings]
[consultation]
[chemotherapy]
His blood lab data indicated that his ferritin level increased by over 30% in less than 20 days after taking iron supplements from time to time.
High ferritin levels suggest an excess of iron or an acute inflammatory reaction in which ferritin is mobilized without excess iron. Ferritin can be used as an indicator of iron overload disorders, such as hemochromatosis or hemosiderosis. Ferritin can increase the liver proinflammatory mediators IL-1b, iNOS, RANTES, IkappaB alpha, and ICAM1. As ferritin is also an acute-phase reactant, it is often elevated in various diseases. A normal C-reactive protein (CRP) can be used to exclude elevated ferritin caused by acute phase reactions. However, our HIS5 does not contain simultaneous data on ferritin levels and CRP levels.
As the body content of iron (iron burden) increases beyond that needed for normal production of red blood cells, muscle cells, and iron-containing enzymes, the plasma iron-binding protein transferrin becomes saturated, eventually exceeding its capacity and resulting in binding of iron to other proteins and molecules, including albumin, citrate, acetate, and others. This iron is referred to as non-transferrin-bound iron (NTBI); it begins to appear once the transferrin saturation exceeds 35 percent and rises significantly with transferrin saturation above 70 percent. NTBI is taken up by cells that have active uptake mechanisms. This includes parenchymal cells of the liver, heart, and endocrine organs. In these affected organs, excess iron can chemically interact with hydrogen peroxide. These reactive oxygen species in turn can cause tissue damage, inflammation, and fibrosis. The liver, heart, joints, and endocrine organs appear to be especially susceptible.
By the time clinical findings have developed (hepatic fibrosis, heart failure, cardiac conduction defect), it is likely that significant iron deposition and tissue injury has occurred. Please ensure that the patient’s iron level is checked as needed and monitor any signs of iron overload if iron supplements are continued.
The lab data indicated that MCV, MCH, MCHC, UIBC were normal; Ferritin was exceeded; Fe (iron bound) and TIBC was low.
Normal MCV, MCH, MCHC may suggest the anemia is less likely to be caused by iron insufficiency. High ferritin may suggest iron overload. Low TIBC can suggest that there is not enough transferrin available to bind to iron, i.e., the patient has high iron level, so most of the transferrin is bound to it, which leaves very little free in his blood. Frequent blood transfusions may cause iron overload.
It is recommended to hold the Foliromin (ferrous sodium citrate) until the cause of the anemia is confirmed to be iron deficiency.
[diagnosis] - 2023-04-06 admission note
[past history] - 2023-04-06 admission note
[allergy]
[family history]
[exam findings]
[consultation]
[SOAP]
[surgical operation]
[chemoimmunotherapy]
2023-03-30 - rituximab 375mg/m2 600mg NS 500mL 8hr D1 + gemcitabine 1000mg/m2 1600mg NS 100mL 30min D2 + oxaliplatin 100mg/m2 150mg D5W 250mL 2hr D2 (R-GemOx)
2023-02-21 - rituximab 375mg/m2 600mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1200mg NS 250mL 30min D2 + liposome doxorubicin 35mg/m2 57mg D5W 250mL 1hr D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 45mg BID PO D2-6 (R-CHOP)
2023-01-27 - rituximab 375mg/m2 600mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1200mg NS 250mL 30min D2 + liposome doxorubicin 35mg/m2 57mg D5W 250mL 1hr D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 45mg BID PO D2-6 (R-CHOP)
2023-01-13 - mitomycin-C 30mg/m2 30mg ST BI 1hr (MMC)
2023-01-06 - mitomycin-C 30mg/m2 30mg ST BI 1hr (MMC)
2022-12-29 - mitomycin-C 30mg/m2 30mg ST BI 1hr (MMC)
2022-12-05 - rituximab 375mg/m2 600mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1200mg NS 250mL 30min D2 + liposome doxorubicin 35mg/m2 57mg D5W 250mL 1hr D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 45mg BID PO D2-6 (R-CHOP)
2022-11-14 - rituximab 375mg/m2 600mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1200mg NS 250mL 30min D2 + liposome doxorubicin 35mg/m2 57mg D5W 250mL 1hr D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 45mg BID PO D2-6 (R-CHOP)
2022-10-13 - rituximab 375mg/m2 600mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1200mg NS 250mL 30min D2 + liposome doxorubicin 35mg/m2 57mg D5W 250mL 1hr D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 45mg BID PO D2-6 (R-CHOP)
2022-09-22 - rituximab 375mg/m2 600mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1200mg NS 250mL 30min D2 + liposome doxorubicin 35mg/m2 57mg D5W 250mL 1hr D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 45mg BID PO D2-6 (R-CHOP)
2022-08-19 - rituximab 375mg/m2 630mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1200mg NS 250mL 30min D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 50mg BID PO D2-6 (R-COP)
Tramadol has been associated with vomiting (5% to 10%). ref: UpToDate.
Opioid administration can induce nausea or vomiting; the pathophysiology includes peripheral inhibitory effects of opioids on gastrointestinal transit or stimulation of the pyloric sphincter, delaying gastric emptying or causing gastroparesis. However, the primary mechanism of opioid-induced nausea and vomiting is central, with direct stimulation of the chemoreceptor trigger zone in the area postrema in the floor of the fourth ventricle. The clinical efficacy of 5-HT3 antagonists in opioid-induced emesis supports the hypothesis that stimulation of the area postrema may also be relevant to morphine-induced emesis in humans. The addition of a prokinetic (e.g., metoclopramide), prochlorperazine, or a 5-HT3 antagonist (-setron) to the opiate regimen is beneficial. ref: Opioids in Gastroenterology: Treating Adverse Effects and Creating Therapeutic Benefits. Clin Gastroenterol Hepatol. 2017;15(9):1338-1349. doi:10.1016/j.cgh.2017.05.014
Roumin (prochlorperazine maleate) has been prescribed properly. There is no medication reconciliation issue with the active prescription.
[diagnosis] - 2023-04-14 admission note
[past history]
[allergy]
[family history]
[exam findings]
[consultation]
[SOAP]
[radiotherapy]
[chemotherapy]
[assessment]
[assessment]
[diagnosis] - 2023-04-07 admission note
[exam findings]
[SOAP]
[surgical operation]
[note]
Gemcitabine plus nanoparticle albumin-bound paclitaxel (nabpaclitaxel) for advanced pancreatic and biliary cancer 2023-04-14 https://www.uptodate.com/contents/image?imageKey=ONC%2F89668
Treatment protocols for pancreatic cancer REGIMENS 2023-04-14 https://www.uptodate.com/contents/treatment-protocols-for-pancreatic-cancer
[assessment]
Brosym (cefoperazone + sulbactam) 4g IVD Q12H has been prescribed fot the patient’s BTI.
It is considered to use nab-paclitaxel plus gemcitabine to treat the patient after her BTI is controlled. Please ensure that the ANC is >1500/uL and the platelet count is >100K/uL prior to administering the regimen. Sepsis has occurred in patients with or without neutropenia (risk factors are biliary obstruction or presence of a biliary stent). During the treatment, it is recommended to initiate broad-spectrum antibiotics in the presence of fever, even if not neutropenic. Interrupt nabpaclitaxel and gemcitabine until sepsis resolves and, if neutropenic, until neutrophils are at least 1500/uL, then resume at lower doses.
No medication reconciliation issues were noted for the patient.
{not completed}
[past history]
[allergy]
[family history]
[exam findings]
[SOAP]
[assessment]
[diagnosis] - 2023-03-24 admission note
[past history]
Dx history: - Gout - IDA - Alzheimer’s disease - CAD - CVA
Surgery history: - C-spine compression fracture s/p over 10 years ago
[allergy]
[family history]
Father: Liver cancer
[lab data]
[exam findings]
[consultation]
[surigcal operation]
[chemotherapy]
The patient has received a reduced dose of 65mg/m2 of oxaliplatin for the first time during this hospitalization, and no adverse reactions have been observed to date.
For the patient’s chronic viral hepatitis B and post-pancreatico-duodenectomy status, Protase (pancrelipase 280mg) TIDCC and Baraclude (entecavir 0.5mg) QDAC have been prescribed.
There is no medication reconciliation issue found.
[exam findings]
[SOAP]
[chemoimmunotherapy]
[exam findings]
[POMR]
[SOAP]
[chemotherapy]
Induction therapy for acute myeloid leukemia in medically-fit adults. 2023-04-10 https://www.uptodate.com/contents/induction-therapy-for-acute-myeloid-leukemia-in-medically-fit-adults
[follow up]
Bicytopenia progresses, Cravit (levofloxacin) and FLU-D (fluconazole) are used to manage potential infections.
No fever in the past 7 days.
Blast decreased after 7+3 anthracycline plus cytarabine since 2023-03-31.
The patient diagnosed with AML was admitted and received the first dose of “3+7 daunorubicin/cytarabine” regimen on 2023-03-31. Lab data showed the development of severe neutropenia following administration of the regimen.
Treatment with the regimen can cause 3 to 5 weeks of profound cytopenias and associated risks of life-threatening infections and bleeding. And cytarabine may cause a flu-like syndrome (including fever and/or rash) and daunorubicin can be associated with infusion reactions and cardiac arrhythmias.
It is recommended that a bone marrow examination be performed 14 to 21 days after initiation of therapy to assess the initial response to the therapy and to determine if a second induction course is needed.
Initial response to therapy - A bone marrow examination on day 14 of treatment provides an assessment of the clearance of blast cells and a preview of the response to induction therapy. Findings from the day 14 examination may be classified as follows:
Institutions vary in their responses to findings of the day 14 bone marrow examination.
Cravit (levofloxacin) and Flu-D (fluconazole) both have been prescribed to prevent or alleviate the patient from infections. There is no problem that is identified with the active recipe.
{not completed}
[exam findings]
[consultation]
{not completed}
[exam findings]
[consultation]
[lab data]
2023-04-11 Ferritin 1154.7 ng/mL
2023-04-11 Transferrin 143.6 mg/dL
2023-04-11 Fe (Iron-bound) 123 ug/dL
2023-04-11 TIBC 206 ug/dL
2023-04-11 UIBC 83 ug/dL
2023-04-10 BUN 29 mg/dL
2023-04-10 Bilirubin direct 0.22 mg/dL
2023-03-21 Direct Coomb Test Positive
2023-03-21 Indirect Coomb Test Positive
2023-03-21 FKLC 156.0 mg/L
2023-03-21 FLLC 193.0 mg/L
2023-03-17 Anti-beta2-glycoprotein-I Ab 9.2 U/mL
2023-03-17 Gamma 44.3 %
2023-03-15 IgG (blood) 2208 mg/dL
2023-03-09 stool FOB Positive
2023-03-09 Transferrin, stool Postive
[diagnosis] - 2023-04-10 admission note
[past history]
[allergy]
[family history]
[exam findings]
[SOAP]
[chemotherapy]
| he tumor marker CEA was found to be elevated and increasing before the first chemotherapy, and further follow-up tests can be ordered as necessary. |
|---|
| 023-03-08 CEA: 217.89 ng/mL |
The treatment strategy planned on 2023-03-21 is based on the results of PET: if it indicates the presence of metastases, the recommended chemotherapy regimen for concurrent chemoradiotherapy (CCRT) and post-CCRT would be FOLFOX, and total neoadjuvant therapy (TNT) would not be necessary. However, if PET shows that the lesion in the liver is not a metastasis, then the recommended treatment would be TNT, which consists of CCRT with FU, followed by FOLFOX for 6-8 cycles, then surgery and postoperative follow-up. The chemotherapy regimen for CCRT in this case would be FU.
On 2023-03-10, the results of the PET scan were available and the patient began receiving the FOLFOX regimen for the first time while in this hospital stay.
According to the patient’s blood glucose records, there is an upward trend and significant variability in his blood glucose levels despite taking Forxiga (dapagliflozin). To address this, it is recommended to investigate if there has been a significant change in the patient’s dietary intake, especially in regards to carbohydrate consumption, as this could have a substantial impact on blood glucose levels.
[exam findings]
[consultation]
[medication]
[note]
Capecitabine 2023-04-11 https://www.uptodate.com/contents/capecitabine-drug-information
[assessment]
The supplemental report for the IHC staining of EGFR, PMS2, MSH6, MSH2, and MLH1 for the colon biopsy pathology performed on 2023-03-10 is still pending and not yet available.
The patient’s last recorded height on 2023-03-30 is 172 cm, and his last recorded weight on 2023-04-10 is 75.7 kg. Based on these measurements, his body surface area (BSA) is calculated to be 1.9 m2. The patient has been receiving capecitabine at a daily dose of 2000 mg since late March 2023, which is a dose of 1052 mg/m2 based on his BSA. This is approximately 84% of the recommended daily dose of 1250 mg/m2.
It appears that the patient has had anemia even before the administration of capecitabine, and the cause may be gastrointestinal bleeding (in case of A-colon lesions?) as evidenced by positive occult blood in the stool. Blood transfusion performed on 2023-03-07, 2023-03-29, and 2023-04-07 and PPI is currently prescribed.
There is currently no record of hand-and-foot syndrome (HFS) or any related symptoms such as palmar-plantar erythrodysesthesia or chemotherapy-induced acral erythema.
[diagnosis] - 2023-04-02 admission note
[past history] - 2023-04-02 admission note
[allergy]
[family history]
[exam findings]
[consultation]
[SOAP}
[surgical operation]
[radiotherapy]
[chemotherapy]
The patient’s sputum Gram’s stain results on 2023-04-02 showed G(+) Cocci 2+, GNB 2+, GPB 3+ (Neutrophil/LPF < 10, Epithelial cell/LPF 15~20). Antibiotics with Betamycin 4.5gm Q6H have been prescribed since the same day to treat the patient’s respiratory symptoms. After checking the PharmaCloud database, no medication reconciliation issue is found.
[ciclosporin TDM]
On 2023-04-08, the patient’s ciclosporin trough concentration was found to be 169ng/mL, which falls within the acceptable range of 100 to 400ng/mL. However, if the target trough concentration is between 200 and 300 ng/mL, then it is recommended to increase the daily dose from the current 200mg to 250mg and continue with regular follow-up testing.
The patient’s kidney function results have returned to normal within the last 7 days.
2023-04-03 Creatinine 0.95 mg/dL
2023-03-31 Creatinine 2.45 mg/dL
2023-03-30 Creatinine 3.10 mg/dL
2023-03-28 Creatinine 3.74 mg/dL
2023-04-03 eGFR 98.94
2023-03-31 eGFR 33.16
2023-03-30 eGFR 25.27
2023-03-28 eGFR 20.35
[cyclosporine IV to PO conversion]
[ciclosporin TDM]
[therapeutic drug monitoring for cyclosporine]
[assessment]
[therapeutic drug monitoring for cyclosporine]
The dose of cyclosporine was increased from the original 140mg to 145mg on a later time on 2023-03-01, and further increased to 170mg on 2023-03-02, while the dosing frequency remained Q12H.
The TDM for cyclosporine was performed on 2023-03-02 at 08:26:39, and the administration time was recorded as 2023-03-02 11:46. The scheduled administration times for Q12H should be 09:00 and 21:00, and the later actual administration time may be due to delayed medication or delayed registration in the system, so it is recommended to confirm the system usage with nursing staff. However, the 08:26 blood draw is consistent with the trough concentration at Q12H.
Since the dose increase has not reached steady state, it is recommended to perform another blood draw in the middle of next week.
[cyclosporine TDM]
[therapeutic drug monitoring]
Sandimmun injection (ciclosporin)
The recommended therapeutic trough concentration range for cyclosporine typically falls within 100-400 ng/mL. The current administration is 140mg IVD Q12H.
Based on the TDM result on 2023-02-23 indicating a level of 43.3 ng/mL, it is suggested to administer a dosage of 180 mg per shot every 12 hours.
It is also recommended to perform another blood test to examine the trough concentration in the latter half of next week.
The echocardiography performed on 2023-01-06 showed an improved LVEF (55% versus 33%) compared to 2022-11-11.
Readings of bilirubin (direct/total) are within normal limits. AST/ALT levels indicate that impaired liver function is improving. There is no need to adjust the dose of medications in the active prescription for liver function. In addition, there is no laboratory evidence of impaired kidney function.
In spite of the fact that Hydrea (hydroxyurea) has been administered since 2023-01-27 afternoon, there has not been an obvious decrease in WBC counts since the second day of administration. The blast percentage remains around 60% with only minor fluctuations.
The PLT count has been trending downward, which should be closely monitored.
The active prescription does not pose a problem.
[drug identification]
We have been requested by the patient’s primary nurse to identify one drug. The drug is identified as Vemlidy (tenofovir alafenamide 25 mg) and is indicated for the treatment of chronic hepatitis B virus (HBV) infection in adults and pediatric patients 12 years of age and older with compensated liver disease. The in-hospital porter will return the identified drug to the ward.
Not used:
[exam findings]
[consultation]
[SOAP]
[multiteam]
[diagnosis] - 2023-04-07 discharge note
[exam findings]
[SOAP]
[chemotherapy]
[note]
TPF regimen (in-hospital Chemotherapy Regimens for Head and Neck Cancer: Collection as of 2022-02-11)
Neoadjuvant Chemotherapy regimen
[assessment]
[exam findings]
[chemotherapy]
[assessment]
Most patients achieve cooling of the oral mucosa through intraoral administration of ice chips during chemotherapy administration. This is a cost effective and proven beneficial treatment.
Both topical and systemic analgesic approaches have been used to manage pain associated with mucositis.
Currently, lidocaine 2% PO PRNQD and tramadol IVD PRNQ6H have been prescribed.
The diet should be limited to foods that do not require significant chewing; acidic, salty, or dry foods should be avoided.
If poor feeding compromises the patient’s nutritional status, placement of a nasogastric feeding tube may be considered.
[diagnosis] - 2023-04-03 discharge note
[lab data]
2023-02-23 HBsAg Nonreactive
2023-02-23 HBsAg (Value) 0.35 S/CO
2023-02-23 Anti-HCV Nonreactive
2023-02-23 Anti-HCV Value 0.07 S/CO
2023-02-23 Anti-HBs 11.15 mIU/mL
2023-02-23 Anti-HBc Reactive
2023-02-23 Anti-HBc-Value 6.43 S/CO
2023-02-23 Anti-HBc IgM Nonreactive
2023-02-23 Anti-HBc IgM Value 0.10 S/CO
2023-02-10 ANA Negative
2023-02-10 LA1 39.3 sec
2023-02-10 LA2 30.7 sec
2023-02-10 LA1/LA2 ratio 1.2
2023-02-08 Anti-Cardiolopin IgG 0.7 GPL-U/mL
2023-02-08 Anti-cardiolipin-IgM <0.8 MPL U/mL
2023-02-08 Anti-β2-glycoprotein-I Ab 0.9 U/mL
2023-02-08 Anti-ENA Sm 1.2 EliA U/ml
2023-02-08 Anti-ENA RNP 1.1 EliA U/ml
[SOAP]
[immunotherapy]
[assessment]
The patient’s PharmaCloud is currently inaccessible. However, based on in-hospital records, the patient received prednisolone at a dose of 80mg daily from 2023-02-08 to 2023-02-22, and dexamethasone at a dose of 8mg daily from 2023-03-10 to 2023-04-07. The patient also received rituximab on 2023-02-23, 2023-03-17, and 2023-04-03.
The peak in PLT count on 2023-03-01 occurred approximately 1 week after the first dose of rituximab and was not during steroid administration. There has been no similar increase since the second dose of rituximab. It is possible that this peak was due to the delayed effect of rituximab, which can take some time for platelet production to increase after treatment. However, without further information, it is difficult to determine the exact cause. Close monitoring of the patient’s platelet levels and response to treatment is recommended.
Lab data from 2023-02-08 and 2023-02-10 showed normal values for ANA, LA1, LA2, LA1/LA2 ratio, anti-cardiolipin IgG, anti-cardiolipin IgM, anti-beta2-glycoprotein-I Ab, anti-ENA Sm, anti-ENA RNP, and PT, INR, APTT.
In the event that rituximab is no longer effective, splenectomy or TPO-RAs may be considered options.
{EGFR wild type Adenocarcinoma of RUL with liver metastases, T4N0M1c, stageIVB - not completed}
[diagnosis] - 2023-04-02 admission note
[past history]
[allergy]
[family history]
[exam findings]
EGFR wild type Adenocarcinoma of RUL with liver metastases,T4N0M1c,stageIVB
Multidetector CT (256-detectors, iCT Philips, was performed with 0.625 mm collimation & 2.5 mm slice thickness)
Chest CT without IV contrast ehnancement shows: Chest: S/p port-A placement with its tip at Superior vena cava. Massive bilateral pleural effuison and loculated effusion at right hemithorax is found. Patent airway is found. There is no evidence of mediastinal LAP
Visible abdomen: Atrophy of both kidneys are found. The GB is well distended without soft tissue lesion The spleen, pancreas and adrenals are intact. Low density lesion at S4 and S2 of liver is found. Liver meta is considered. In comparison with CT dated on 2022-09-28, regression of the tumor is found. There is no evidence of paraarotic LAPs. There is no ascites accumulation at abdominal cavity. Suggest clinical correlation
Imp: Loculated effusion at both hemithorax. Liver tumor, in regression.
History:眩暈,想吐,表偶爾會流鼻水,有血絲 Nausea without vomit for 2-3 days, mild dizziness SOB sometimes, very mild Abd distension since last chemo(6 days ago) 20220705 CT：RUL lung ca & liver mets;T3N2M1c, cSTAGE:IVB
MD CT (Aquilion Prime SP) of the abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. CT with axial and coronal reformated isotropic images were obtained in non-contrast scan.
This patient did not receive IV contrast administration. Small visceral, intra-abdominal and retroperitoneal lesion may be difficult to detect. Either vascular patency or organ pefusion status can not be determined without IV contrast.
Findings: 1. Prior CT identified liver metastases in both lobes are noted again, mild decreasing in size. Please correlate with contrast enhanced dynamic CT or MRI. 2. There are bilateral extensive destructive centrilobular emphysema with upper lobes predominant. Prior CT identified RUL lung periphereal mass measuring 5.2 cm is noted again, decreasing in size. Please correlate with contrast enhanced CT. 3. Prior CT identified few cysts in S1 and S2 are noted again, stationary. 4. There are several renal stones, bilateral. Both kidney show small size and thin parenchyma that are c/w chronic renal disease. 5. There is no hyper-or hypodense lesion in the gallbladder, biliary system, pancreas, and spleen. There is no ascites or lymphadenopathy. There is no bowel wall thickening, and no bowel obstruction. The abdominal aorta and IVC are grossly unremarkable. There is no evidence of intrinsic or extrinsic bladder mass. There is no focal lesion over the mesentery and omentum.
IMP: 1. Prior CT identified liver metastases in both lobes are noted again, mild decreasing in size. Please correlate with contrast enhanced dynamic CT or MRI. 2. Prior CT identified RUL lung periphereal mass measuring 5.2 cm is noted again, decreasing in size. Please correlate with contrast enhanced CT.
[SOAP]
[chemotherapy] (not completed)
2023-01-05 - docetaxel 35mg/m2 54mg D5W 150mL 1hr (WBC 1.3K/uL 2023-01-12, WBC 2.15K/uL 2023-01-14)
2022-12-15 - ditto (WBC 1.87K/uL 2022-12-22, WBC 1.42K/uL 2022-12-26)
2022-12-01 - ditto (WBC 2.54K/uL 2022-12-13)
2022-11-15 - ditto (WBC 2.67K/uL 2022-11-29)
2022-11-03 - ditto
2022-10-25 - ditto
2022-10-18 - ditto
2022-10-06 - ditto
2022-09-22 - ditto
2022-09-15 - ditto
2022-09-01 - ditto
2022-08-25 - ditto
2022-08-10 - ditto
2022-07-19 - pemetrexed 500mg/m2 818mg NS 100mL 10min + NS 500mL 1hr (before cisplatin) + cisplatin 75mg/m2 120mg NS 500mL 3hr + NS 500mL 1hr (after cisplatin)
[medication]
[assessment]
[diagnosis] - 2023-04-02 admission note
[past history]
[allergy]
[family history]
[lab data]
2023-04-03 HBsAg Nonreactive
2023-04-03 HBsAg (Value) 0.52 S/CO
2023-04-03 Anti-HBc Nonreactive
2023-04-03 Anti-HBc-Value 0.91 S/CO
2023-04-03 Anti-HCV Nonreactive
2023-04-03 Anti-HCV Value 0.05 S/CO
2023-04-03 Anti HTLV I/II Nonreactive
2023-04-03 Anti HTLV I/II Value 0.05 S/CO
2023-04-03 HIV Ab-EIA Nonreactive
2023-04-03 Anti-HIV Value 0.06 S/CO
2023-04-03 CMV_IgG Reactive
2023-04-03 CMV_IgG Value 213.4 AU/mL
2023-04-03 CMV IgM Nonreactive
2023-04-03 CMV IgM Value 0.23 Index
[exam findings]
[consultation]
[radiotherapy]
[chemoimmunotherapy] (not completed)
[note]
Diffuse large B cell lymphoma (DLBCL): Suspected first relapse or refractory disease in medically-fit patients (ref: https://www.uptodate.com/contents/diffuse-large-b-cell-lymphoma-dlbcl-suspected-first-relapse-or-refractory-disease-in-medically-fit-patients)
[diagnosis] - 2023-04-01 admisstion note
[present illness] - 2023-04-01 admisstion note
[exam findings]
[SOAP]
[assessment]
The patient’s fever appears to have improved (with a temperature not exceeding 37.5 degrees Celsius) since the administration of Flumarin (flomoxef) on 2023-04-01. However, blood and urine cultures are not yet available.
The patient has a high bilirubin level and is icteric 2+. The elevation of serum alkaline phosphatase, which is out of proportion to the serum aminotransferases, indicates possible biliary obstruction or intrahepatic cholestasis. An increased serum alkaline phosphatase is also observed in granulomatous liver diseases, such as tuberculosis or sarcoidosis.
Based on the CT performed on 2023-04-01, there is evidence of liver, lung, lymph node metastasis, and peritoneal carcinomatosis. Further evaluation is recommended, such as ultrasound, magnetic resonance cholangiopancreatography (MRCP), or endoscopic retrograde cholangiopancreatography (ERCP) to investigate the presence of intra- or extrahepatic bile duct dilation.
The patient was prescribed Vemlidy (tenofovir alafenamide) appropriately following a positive anti-HBc test result on 2023-03-14.
According to PharmaCloud records, medications were prescribed for pulmonary symptoms at Cardinal Tien Hospital in January 2023. If these symptoms are no longer present, then there are no medication reconciliation issues.
[diagnosis] - 2023-03-30 admission note
[exam findings]
[assessment]
[diagnosis] - 2023-03-10 discharge note
[exam findings]
[consultation]
[SDM] - 2023-02-02
[surgical operation]
[chemotherapy]
Induction chemotherapy should be used when chemotherapy occurs before radiation therapy. The term neoadjuvant chemotherapy should be used to refer to chemotherapy before surgery. ref: https://www.healthline.com/health/cancer/induction-chemotherapy
[assessment]
The patient has received (planned total 9-dose) TPF neoadjuvant regimen on 6 occasions, specifically on 2023-02-03, 2023-02-13, 2023-02-27, 2023-03-06, 2023-03-22, and 2023-03-31 (the 6th time during this hospitalization). There was only one episode of WBC less than 3K/uL, which occurred on 2023-02-10, approximately 1 week after the first dose. Otherwise, no other episodes of low WBC count were observed.
The TPF regimen was appropriately dose reduced from the second dose, with docetaxel at 32mg/m2 instead of 40mg/m2, cisplatin at 32mg/m2 instead of 40mg/m2, and fluorouracil at 900-800mg/m2 instead of 1000mg/m2. G-CSF was also used in a timely manner.
According to the latest information, there are no moderate or severe complaints for the patient about adverse reactions.
By the way, there is a decreasing trend in HGB, which indicates that the HGB does not seem to be fully recovered at the current administration interval/frequency. Please continue monitoring and check for need for blood transfusion for the next 3 scheduled doses.
[diagnosis] - 2023-03-09 admission note
[lab data]
[exam findings]
[consultation]
[SOAP]
[chemotherapy]
2023-03-30 CRP 18.82mg/dL, WBC 12.95K/uL, urine bacteria 1+, urine protein 1+. Blood culture results are not yet available.
There have been no medication reconciliation issues found in the patient. (PharmaCloud not accessible)
[present illness] - 2023-03-29 admission note
This is 77-year-old man who has past medical history of Raynaud phenomenon, Diabetes Type II, right lung adenocarcioma RLL status post VATS wedge resection, prostatic cancer status post TURP under regular oral endoxan and prednisolone. This time, he complained of dyspnea for days, OPD CXR showed right pleural effusion. Loss 5 kg due to poor appetite in one month according to himself. He was admitted to our ward for further evalation and treatment.
[past history]
[allergy]
[family history]
[SOAP]
[medication]
[assessment]
[diagnosis] - 2023-03-06 admission note
[past history]
Heart:(-)
Liver:(-)
Kidney:(-)
H/T:(-)
DM:(-) Other
DVT 2 years ago
medication: Rivaroxaban regularly and had taken Leuplin
Surgical: denied
Menstrual history: G0P0, Last menstrual period: 2022-09-25
sex –
Menarche at the age of 12 years old
Menstrual cycle:irregular with duration of 7 days
Amount: moderate with blood clots
Pap smear: denied
[allergy]
[family history]
[exam findings]
[surgical operation]
[radiotherapy]
[chemotherapy]
On 2023-03-29, the patient’s lab results indicated generally normal blood cell counts, selected electrolytes, and liver/kidney functions. There is no evidence that contraindicates the scheduled chemotherapy. The patient was diagnosed with acute embolism and thrombosis of the femoral and iliac veins on 2020-11-16 and has been taking Xarelto (rivaroxaban) for this condition. After reviewing the PharmaCloud database, no medication reconciliation issues were identified.
After a leukopenia event (WBC 1.65K/uL on 2022-12-31), all subsequent data showed WBC counts above 5K/uL. Since receiving paclitaxel + carboplatin regimen in late November 2022, there have been no observations of anemia and/or thrombocytopenia. The patient is currently taking rivaroxaban as a self-carried medication due to a history of DVT. No medication reconciliation issues were found during this hospital stay.
Based on the lab results (2022-12-19), the scheduled chemotherapy did not appear to be contraindicated.
[diagnosis] - 2023-03-03 admission note
[past history]
[allergy]
[family history]
[exam findings]
Right liver cysts (3.57x4.19cm, 1.26x1.32cm).
Gallbladder stones (3-5mm).
2023-01-06 SONO - thyroid gland.
2023-01-06, 2022-12-02, -10-28 Nasopharyngoscopy
2022-11-24 Gynecologic ultrasonography
2022-11-16 CT - abdomen
2022-09-08 MRI - nasopharynx
2022-09-01, -06-02 SONO - abdomen
2022-06-14 ECG
2022-06-14 CXR
2022-06-14 PTA
2022-04-28 Tc-99m MDP whole body bone scan
2022-04-28 Gynecologic ultrasonography
2022-04-27 Panendoscopy
2022-04-27 SONO - abdomen
2022-04-26 MRI - nasopharynx
2022-04-26 PTA
2022-04-25 ECG
2022-04-18 PTA
2022-04-11 Patho - nasopharyngeal/oropharyngeal biopsy
2022-04-11 Otologic endoscopy
2022-04-11 Nasopharyngoscopy
2022-03-12 SONO - abdomen
2020-12-16 2D transthoracic echocardiography
[SOAP]
[radiotherapy]
[chemoimmunotherapy]
The patient was prescribed ergometrine maleate for an unspecified leiomyoma of uterus by our gynecologist on 2023-03-03. However, this drug is not currently shown in the active medication list. It has no known interaction with the patient’s current medications. Therefore, adding it as a self-carried item to the active medication list is recommended for proper medication reconciliation.
In addition, it is noted that fluorouracil, metoclopramide, and hydroxychloroquine are potential QT-prolonging agents. Administration of these drugs in an overlapping manner may enhance the QTc-prolonging effect, which should be monitored.
[exam findings]
[SOAP]
[radiotherapy]
[chemotherapy]
[assessment]
The patient was diagnosed with low rectal cancer involving the anal canal with bleeding, cT4bN1bM0, stage: IIIC.
For patients with locally advanced rectal cancer who are at high risk for a margin-positive resection or node-positive disease with a low-lying rectal tumor, total neoadjuvant therapy (TNT) is suggested instead of long-course CRT or short-course RT alone. TNT combines oxaliplatin-based chemotherapy with long-course CRT or short-course RT, leading to increased chemotherapy compliance, improved local control, and the ability to consider nonoperative treatment if the patient declines surgery.
The patient has been admitted to receive her first dose of FOLFOX. Lab results on 2023-03-23 showed normal liver and kidney function, blood cell counts, serum electrolytes, and no contraindications to chemotherapy.
The patient’s chronic viral hepatitis B without the delta agent is currently being managed with Baraclude (entecavir).
The current active prescription has no identified issues.
[exam findings]
[consultation]
[surgical operation]
[chemotherapy]
[assessment]
The patient experienced nadir levels in her WBC and/or PLT count approximately one week after receiving chemotherapy, as indicated by asterisks in the table below (WBC < 3K/uL, PLT < 100K/uL).
The patient was admitted for her scheduled chemotherapy with a 20% dose reduction of paclitaxel due to her not fully recovered low PLT level.
No medication reconciliation issues were found after reviewing PharmaCloud and comparing it to the active prescription.
[exam findings]
[assessment]
[past history] - 2023-03-25 admission note
[allergy]
[family history]
[exam findings]
[consultation]
[SOAP]
[chemotherapy]
[medication]
[assessment]
[diagnosis] - 2023-03-27 admission note
[exam findings]
[consultation]
[surgical operation]
[chemotherapy]
The patient underwent surgery for feeding jejunostomy and port-A placement on 2023-02-20 and she began receiving cisplatin and fluorouracil starting from 2023-02-27.
Patients who have undergone feeding jejunostomy surgery often require additional nutritional support and close monitoring of their hydration status. All the oral drugs in the current prescription are compatible with tube feeding.
[diagnosis] - 2023-03-27 admission note
[past history]
[allergy]
[family history]
[exam findings]
[surigcal operation]
[chemoimmunotherapy]
2023-03-27 - oxaliplatin 70mg/m2 100mg D5W 250mL 2hr + irinotecan 150mg/m2 230mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (FOLFOXIRI)
2023-03-01 - oxaliplatin 70mg/m2 100mg D5W 250mL 2hr + irinotecan 150mg/m2 230mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 3700mg NS 500mL 46hr (FOLFOXIRI)
2023-02-07 (Avastin + FOLFOX)
2023-01-09 (Avastin + FOLFOX)
2022-12-12 (Avastin + FOLFOX)
2022-11-18 (Avastin + FOLFOX)
2022-10-26 (Avastin + FOLFOX)
2022-07-04 (Avastin + FOLFIRI)
2022-06-08 (Avastin + FOLFIRI)
2022-05-16 (Avastin + FOLFIRI)
2022-04-20 (Avastin + FOLFIRI)
2022-03-29 (Avastin + FOLFIRI)
2022-03-04 (Avastin + FOLFIRI)
2022-02-11 (Avastin + FOLFIRI)
2022-01-12 (Avastin + FOLFIRI)
2021-12-27 (Avastin + FOLFIRI)
[assessment]
[diagnosis] - 2023-03-28 discharge note
[exam findings]
[consultation]
[surgical operation]
[radiotherapy]
[chemotherapy]
{Chronic myelomonocytic leukemia, CMMoL}
[ciclosporin TDM]
Based on the available system records, the blood for ciclosporin was drawn at 00:48 on 2023-03-27, approximately 4 hours after medication administration at 20:32 on 2023-03-26. If the purpose of the blood draw was to measure the trough concentration, the ideal time to draw blood is within 30 minutes before next scheduled medication administration. Therefore, it is recommended to verify the accuracy of the system records or to redraw a blood sample at the appropriate time for accurate measurement.
The recorded concentration result for ciclosporin is 331.4ng/mL, but its accuracy as a trough level may be questionable due to the possibility of an inappropriate blood draw time.
The peak concentration of cyclosporine-A was 326 ng/mL on 2022-12-12, which is within the normal therapeutic range.
2022-12-13 WBC 670/uL, PLT 2000/uL.
[cyclosporine trough concentration]
As a follow-up of the change in dose of cyclosporine from 100mg Q12H to 120mg Q12H since 2022-11-25, it is recommended that the trough concentration of cyclosporine be renewed by drawing blood within 30 minutes of the first dose on 2022-11-29.
[cyclosporine trough concentration]
Following the administration of 100 mg Q12H since 2022-11-21, a blood sample was taken for cyclosporine trough concentration, and the level was 63.9 ng/mL. In general, the effective range is considered to be between 100 and 400 ng/mL. In the event that the clinical effect not shown, increasing the daily dose to 300mg (divided in 3 seperate administration) can be considered and then recheck the trough concentration 3 days after the dose alteration. The goal is to limit the concentration with a minimum dose while retaining the necessary clinical effect.
According to UpToDate database, cyclosporine for patients with altered kidney function, CrCl <60 mL/minute: No dosage adjustment necessary (0.1% excreted in the urine unchanged) (Nemecek 2019; expert opinion). For nontransplant indications (eg, autoimmune disease), the manufacturer’s labeling states use is contraindicated in patients with abnormal renal function (not defined); however, when potential benefits outweigh the risks, may consider cautious use with frequent monitoring of kidney function, or consider use of an alternative agent due to increased risk of worsening kidney function, especially for patients with more severe impairment (expert opinion).
2022-10-20 eGFR 35. The dosage of prescribed drugs is within the recommended range for patients with altered kidney function.
[Diagnosis] - 2023-03-27 admission note
[present illness] - 2023-03-27 admission note
[past history] - 2023-03-27 admission note
[allergy]
[family history]
[exam findings]
[surgical operation]
[chemotherapy]
[assessment]
[diagnosis] - 2023-03-13 admission note
[past history]
[allergy]
[family history]
[exam findings]
MRI (111-2-5, NTUH): 1. operative change of the left lobe of liver; no evidence of local residual tumor is noted; 2. focal area 39.5mm in the surgical margins is noted; the lesion was not identified on MR 2020/9/8; new recurrent tumor is considered. (arrow key images) 3. hepatic veins and portal veins are patent 4. there are no focal lesions in the spleen pancreas both adrenal and kidneys; a tiny cyst in the left kidney; 5. there is no evidence of paraaortic LAPs in abdomen; there is no evidence of paraaortic LAPs in pelvic cavity and bilateral inguingal areas. 6. there is no ascites 7. enlarged prostate is noted with posterior urinary bladder indentation; 8. hydrocele of the left scrotum. PET (111-3-2, NTUH): Some intense hot areas along medial border of the liver (figures 1-1 to 1-4, SUVmax=11.85). * Some moderate hot spots at abdominal paraaortic nodes and left iliac nodes (figures 1-5 to 1-9, SUVmax=5.79). * A faint hot spot at right iliac crest (figure 1-10, SUVmax=1.34), probably benign. * Some mild hot areas at L1-L2 vertebral junction, right hip joint, and right ischial enthesis, probably arthritis and enthesitis. * Intense curvilinear-shaped hot areas at bowel loops, suspicious Metformin-related activity. Pathology (P2202854, 2022-3-26, NTUH): Liver segment 5 8 anatomical hepatectomy cholangiocarcinoma Gallbladder cholecystectomy chronic cholecystitis Lymph node peri-gallbladder lymphadenectomy minimal histological change (1/1). Histologic Grade Grade 2: Moderately differentiated (50% to 95% of tumor composed of glands). Margins (check all that apply) Hepatic Parenchymal Margin Uninvolved by invasive carcinoma. Lymph-Vascular Invasion: not identified. Perineural Invasion Not identified. Pathologic Staging (pTNM according to AJCC v.8): Primary Tumor (pT) pT1b: Solitary tumor ＞5cm without vascular invasion Regional Lymph Nodes (pN) pN0: No regional lymph node metastasis. MRI (111-5-4, NTUH): 1. operative change of the left lobe of liver; no evidence of local residual tumor is noted; 2. operative change of the anterior right lobe of liver; no evidence of local residual tumor is noted; a small biloma. 3. a recurrent tumor 34.5mm is noted at the S1 of the liver; cholangiocarcinoma is considered. 4. hepatic veins and portal veins are patent 5. there are no focal lesions in the spleen pancreas both adrenal and kidneys 6. there is no evidence of paraaortic LAPs in abdomen 7. there is no ascites
[consultation]
[radiotherapy]
[chemotherapy]
[exam findings]
[consultation]
[chemotherapy]
[exam findings]
[consultation]
[cancer multidisciplinary team meeting conclusion] - meeting date: 20221111
[chemoimmunotherapy]
[mucositis]
As of now, Comfflam Anti-inflammatory Spray (benzydamine 1.5 mg/mL) is available in this hospital and can be used as a rinse three to four times daily (depending on the severity of the mucositis).
{not completed}
[diagnosis] - 2023-03-22 admission note
[past history]
Irregular drug use
[allergy]
[family history]
[exam findings]
[consultation, not completed]
[radiotheray]
[chemotherapy]
[assessment]
[diagnosis] - 2023-03-22 admission note
[past history] - 20221213 admission note
[family history]
[exam findings]
[consultation]
[surgical operation]
[chemoimmunotherapy]
[assessment 2023-01-14, not posted]
[assessment]
The patient had developed tinea unguium in Jan 2023, but there is no longer any evidence of the condition in the updated medical records.
The patient is currently admitted for his 10th cycle of Avastin + FOLFIRI chemoimmunotherapy, and it is planned that he will receive a total of 12 cycles. His liver and kidney function, as well as his electrolyte levels, are normal, although there is a slight anemia based on the 2023-03-21 lab results.
There were no medication reconciliation issues found in the patient.
CT results from 2023-01-31 indicate the presence of focal peritoneal infiltrates, which could suggest post-operative changes or disease recurrence. Further diagnostic tests or imaging studies may be necessary to make a definitive diagnosis and determine whether new treatment should be planned.
{not completed}
[exam findings]
[consultation]
[multiteam]
[surgical operation]
[radiotherapy]
[chemotherapy]
PharmaCloud database reports that Natrilix (indapamide) has been prescribed at VGHTPE on 2022-12-29 as a 84-day refillable prescription, along with other medications such as Norvasc (amlodipine), Betaloc (metoprolol), and Olmetec (olmesartan) to manage the patient’s hypertension. And this patient developed hyponatremia since 2023-02.
Indapamide is a type of diuretic known as a low-ceiling diuretic, which functions by inhibiting the sodium-chloride co-transporter in the kidneys. This leads to an increase in the excretion of both sodium and water from the body.
Treatment of diuretic-induced hyponatremia consists of discontinuing the diuretic and administering either isotonic saline or, if the hyponatremia is severe or symptomatic, hypertonic saline. There is a potential risk of overly rapid correction of the hyponatremia with either regimen. Once the diuretic has been cleared and the patient becomes euvolemic, antidiuretic hormone (ADH) release will be appropriately suppressed, resulting in the excretion of a dilute urine, which can lead to rapid excretion of the excess water. Thus, patients with moderate to severe hyponatremia must be monitored carefully during treatment to minimize the risk of osmotic demyelination.
It is recommended to monitor serum Na levels at a frequency no less than every 12 hours, ensuring that any changes in serum Na levels do not exceed 4-6mEq/L within a 24-hour period to avoid the development of osmotic demyelination syndrome (ODS). Additionally, it is advised to monitor urine output and neurological symptoms. Other recommended tests include checking serum osmolality, TSH, free T4, ACTH (at 8 am), cortisol (at 8 am), urine osmolality, Na, and Cre.
[exam findings]
[consultation]
[exam findings]
[consultation]
[assessment]
{Metastatic colon adenocarcinoma in liver S4-5-8 & S6, pTxN0M1a Stage IVA, post segmental hepatectomy on 2019-06-05}
[diagnosis] - 2023-03-20 admission note
[past history] - 2022-11-25 admission note
[family history]
[lab data]
[exam findings]
A metastasis 3.9 x 2 cm in S7 of the liver S/P C/T with stable disease.
2019-11-21 Whole body PET scan
2019-11-11 CT - abdomen
2019-08-14 Tc-99m MDP whole body bone scan
2019-08-03 MRI - liver, spleen
2019-06-06 Surgical pathology Level V
2019-06-08 CT - abdomen
2019-05-20 CT - abdomen
2018-11-16 CT
2018-07-07 CT
2018-06-28 Surgical pathology Level III
2018-04-26 Surgical pathology Level VI
[consultation]
[surgical operation]
[chemotherapy]
dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
2022-11-25 - cetuximab 250mg/m2 480mg 2hr + oxaliplatin 60mg/m2 115mg 2hr + irinotecan 150mg/m2 290mg 90min + leucovorin 400mg/m2 780mg 2hr + 5-Fu 2800mg/m2 5450mg 46hr (FOLFOXIRI Zhang_ShouYi)
2022-11-08 - cetuximab 250mg/m2 490mg 2hr + oxaliplatin 60mg/m2 118mg 2hr + irinotecan 150mg/m2 295mg 90min + leucovorin 400mg/m2 780mg 2hr + 5-Fu 2800mg/m2 5500mg 46hr (Zhang_ShouYi)
2022-10-20 - cetuximab 250mg/m2 485mg 2hr + oxaliplatin 60mg/m2 116mg 2hr + irinotecan 150mg/m2 290mg 90min + leucovorin 400mg/m2 775mg 2hr + 5-Fu 2800mg/m2 5430mg 46hr (Zhang_ShouYi)
2022-08-12 - cetuximab 250mg/m2 500mg 2hr + oxaliplatin 60mg/m2 120mg 2hr + irinotecan 180mg/m2 290mg 90min + leucovorin 400mg/m2 780mg 2hr + 5-Fu 2800mg/m2 5470mg 46hr (Zhang_ShouYi)
2022-09-12 - cetuximab 250mg/m2 500mg 2hr + oxaliplatin 60mg/m2 120mg 2hr + irinotecan 150mg/m2 290mg 90min + leucovorin 400mg/m2 780mg 2hr + 5-Fu 2800mg/m2 5470mg 46hr (Zhang_ShouYi)
2022-08-26 - cetuximab 250mg/m2 500mg 2hr + oxaliplatin 60mg/m2 120mg 2hr + irinotecan 150mg/m2 290mg 90min + leucovorin 400mg/m2 780mg 2hr + 5-Fu 2800mg/m2 5520mg 46hr (Zhang_ShouYi) patient asked to add oxaliplatin back.
2022-08-12 - cetuximab 250mg/m2 500mg 2hr + irinotecan 180mg/m2 350mg 90min + leucovorin 400mg/m2 800mg 2hr + 5-Fu 2800mg/m2 5500mg 46hr (Zhang_ShouYi)
2022-07-21 - cetuximab 250mg/m2 500mg 2hr + irinotecan 180mg/m2 360mg 90min + leucovorin 400mg/m2 800mg 2hr + 5-Fu 2800mg/m2 5600mg 46hr (Zhang_ShouYi)
2022-07-01 - cetuximab 250mg/m2 500mg 2hr + irinotecan 160mg/m2 320mg 90min + leucovorin 400mg/m2 800mg 2hr + 5-Fu 2800mg/m2 5600mg 46hr (Zhang_ShouYi)
2022-06-14 - cetuximab 250mg/m2 500mg 2hr + irinotecan 160mg/m2 320mg 90min + leucovorin 400mg/m2 800mg 2hr + 5-Fu 2800mg/m2 5600mg 46hr (Zhang_ShouYi) FOLFIRI
2022-05-24 - cetuximab 250mg/m2 500mg 2hr + oxaliplatin 60mg/m2 120mg 2hr + irinotecan 185mg/m2 370mg 90min + leucovorin 400mg/m2 800mg 2hr + 5-Fu 2800mg/m2 5600mg 46hr (Zhang_ShouYi)
2022-04-27 - cetuximab 400mg/m2 500mg 2hr + oxaliplatin 60mg/m2 100mg 2hr + irinotecan 185mg/m2 360mg 90min + leucovorin 400mg/m2 790mg 2hr + 5-Fu 2800mg/m2 5500mg 46hr (Zhang_ShouYi)
2022-03-29 - cetuximab 400mg/m2 500mg 2hr + oxaliplatin 60mg/m2 100mg 2hr + irinotecan 185mg/m2 360mg 90min + leucovorin 400mg/m2 790mg 2hr + 5-Fu 2800mg/m2 5500mg 46hr (Zhang_ShouYi)
2022-03-15 - cetuximab 250mg/m2 500mg 2hr + oxaliplatin 60mg/m2 100mg 2hr + irinotecan 185mg/m2 360mg 90min + leucovorin 400mg/m2 790mg 2hr + 5-Fu 2800mg/m2 5500mg 46hr (Zhang_ShouYi)
2022-02-10 - cetuximab 400mg/m2 700mg 2hr + oxaliplatin 60mg/m2 100mg 2hr + irinotecan 185mg/m2 360mg 90min + leucovorin 400mg/m2 780mg 2hr + 5-Fu 2800mg/m2 5500mg 46hr (Zhang_ShouYi)
2022-01-14 - oxaliplatin 60mg/m2 100mg 2hr + irinotecan 170mg/m2 330mg 90min + leucovorin 400mg/m2 790mg 2hr + 5-Fu 2800mg/m2 5500mg 46hr (Zhang_ShouYi)
2021-12-22 - oxaliplatin 60mg/m2 100mg 2hr + irinotecan 160mg/m2 300mg 90min + leucovorin 400mg/m2 760mg 2hr + 5-Fu 2800mg/m2 5480mg 46hr (Zhang_ShouYi)
2021-12-01 - oxaliplatin 60mg/m2 100mg 2hr + irinotecan 150mg/m2 290mg 90min + leucovorin 400mg/m2 760mg 2hr + 5-Fu 2800mg/m2 5480mg 46hr (Zhang_ShouYi)
2021-11-11 - oxaliplatin 60mg/m2 100mg 2hr + irinotecan 150mg/m2 280mg 90min + leucovorin 400mg/m2 760mg 2hr + 5-Fu 2800mg/m2 5345mg 46hr (Zhang_ShouYi) FOLFOXIRI
2021-09-28 ~ 2021-11-09 - Stivarga (regorafenib 40mg/tab) 4# QD D1-21 Q4W
2021-09-03 - oxaliplatin 85mg/m2 170mg 2hr + leucovorin 400mg/m2 800mg 2hr + 5-Fu 2800mg/m2 5600mg 46hr (Zhang_ShouYi)
2021-08-20 - oxaliplatin 85mg/m2 170mg 2hr + leucovorin 400mg/m2 800mg 2hr + 5-Fu 2800mg/m2 5640mg 46hr (Zhang_ShouYi)
2021-07-29 - oxaliplatin 70mg/m2 140mg 2hr + leucovorin 400mg/m2 805mg 2hr + 5-Fu 2800mg/m2 5660mg 46hr (Zhang_ShouYi)
2020-08-24 - bevacizumab 5mg/kg 200mg 1.5hr + irinotecan 180mg/m2 350mg 1.5hr + leucovorin 400mg/m2 750mg 2hr + 5-Fu 2800mg/m2 5470mg 46hr (Zhang_ShouYi)
2020-07-27 - bevacizumab 5mg/kg 300mg 1.5hr + irinotecan 180mg/m2 350mg 1.5hr + leucovorin 400mg/m2 750mg 2hr + 5-Fu 2800mg/m2 5480mg 46hr (Zhang_ShouYi)
2020-06-29 - bevacizumab 5mg/kg 300mg 1.5hr + irinotecan 180mg/m2 350mg 1.5hr + leucovorin 400mg/m2 750mg 2hr + 5-Fu 2800mg/m2 5460mg 46hr (Zhang_ShouYi)
2020-06-15 - bevacizumab 5mg/kg 300mg 1.5hr + irinotecan 180mg/m2 350mg 1.5hr + leucovorin 400mg/m2 750mg 2hr + 5-Fu 2800mg/m2 5470mg 46hr (Zhang_ShouYi)
2020-05-28 - bevacizumab 5mg/kg 300mg 1.5hr + irinotecan 160mg/m2 300mg 1.5hr + leucovorin 400mg/m2 750mg 2hr + 5-Fu 2800mg/m2 5470mg 46hr (Zhang_ShouYi)
2020-05-07 - bevacizumab 300mg 90min + irinotecan 120mg/m2 250mg 90min + leucovorin 400mg/m2 650mg 2hr + 5-Fu 400mg/m2 650mg 15min + 5-Fu 1000mg/m2 1500mg 20hr D1-2 (Liu_JunHuang)
2020-04-20 - bevacizumab 300mg 90min + irinotecan 120mg/m2 220mg 90min + leucovorin 400mg/m2 560mg 2hr + 5-Fu 400mg/m2 560mg 15min + 5-Fu 1000mg/m2 1500mg 20hr D1 (Liu_JunHuang)
2020-04-02 - bevacizumab 400mg 90min + irinotecan 280mg 90min + leucovorin 400mg/m2 760mg 2hr + 5-Fu 400mg/m2 760mg 15min + 5-Fu 1000mg/m2 1900mg 20hr D1 (Liu_JunHuang)
2020-03-16 - bevacizumab 400mg 90min + irinotecan 280mg 90min + leucovorin 400mg/m2 760mg 2hr + 5-Fu 400mg/m2 760mg 15min + 5-Fu 1000mg/m2 1900mg 20hr D1-2 (Liu_JunHuang)
2020-03-02 - bevacizumab 400mg 90min + irinotecan 280mg 90min + leucovorin 400mg/m2 760mg 2hr + 5-Fu 400mg/m2 760mg 15min + 5-Fu 1000mg/m2 1900mg 20hr D1-2 (Liu_JunHuang)
2020-02-17 - bevacizumab 400mg 90min + irinotecan 280mg 90min + leucovorin 400mg/m2 760mg 2hr + 5-Fu 400mg/m2 760mg 15min + 5-Fu 1000mg/m2 1900mg 20hr D1-2 (Liu_JunHuang)
2020-02-03 - irinotecan 270mg 1.5hr + leucovorin 400mg/m2 760mg 0hr + 5-Fu 400mg/m2 760mg 15min + 5-Fu 1000mg/m2 1900mg 20hr D1-2 (Liu_JunHuang)
2020-01-13 - oxaliplatin 85mg/m2 2hr + leucovorin 200mg/m2 380mg 0hr + 5-Fu 400mg/m2 684mg 15min D1-2 + 5-FU 1000 mg 20hr D1-2 (Liu_JunHuang)
2019-12-06 ~ 2019-12-28 - capecitabine
2019-06-12 - FOLFIRI + bevacizumab
2019-05-28 - FOLFIRI + bevacizumab
2019-05-07 - FOLFIRI + bevacizumab
2019-04-20 - FOLFIRI + bevacizumab
2019-04-03 - FOLFIRI + bevacizumab
2019-03-16 - FOLFIRI + bevacizumab
2019-03-02 - FOLFIRI + bevacizumab
2019-02-17 - FOLFIRI + bevacizumab
2019-02-03 - FOLFIRI
2019-01-03 - FOLFIRI
2018-06-08 ~ 2018-06-18: capecitabine
The control of blood sugar is better than it was during the last hospital stay. As far as the active prescription is concerned, there is no problem.
The patient continues to have poor blood sugar control despite treatment with acarbose, metformin, and vildagliptin (2 data points over 244 mg/dL on 2022-11-08 and 2022-11-09). SGLT2 inhibitors such as Canaglu (canagliflozin), Forxiga (dapagliflozin) or Jardiance (empagliflozin) might be added to help manage diabetes.
Although the patient is currently receiving 3 classes of oral antidiabetic medications (metformin, sitagliptin, and dapagliflozin), his blood sugar remains high (381mg/dL on 2022-09-12 17:35, 302mg/dL on 2022-09-13 06:46); HbA1c of 8.4 (2022-08-26 lab), mild diabetic retinopathy has been confirmed (2022-03-15 ophthalmology).
Starting basal insulin (e.g., Toujeo (insulin glargine)) at 0.1 unit/kg/day or 10 units/day is recommended.
Irinotecan 180 mg/m2 in current regimen is considered a normal dose range for patients with ALT/AST 43/44, BUN 10 (2022-07-21).
There is a history of T2DM in this patient. The most recent HbA1c record dates from 2019, and the AC blood sugar readings have been 271, 327, and 267 since this hospitalization. As there is no hypoglycemic agent in active prescriptions, metformin 500 mg BID is recommended.
CT and MRI in mid January 2022 showed the disease progressed compared to previous images.
CEA readings since July 2021 at intervals of two to three months showed a peak in November 2021 (1261ng/mL) and a slight fall in February 2022 (886ng/mL), possibly caused by the introduction of FOLFOXIRI from November 2021 (ongoing).
[diagnosis]
[past history]
[allergy]
[family history]
[exam findings]
[surgical operation]
[chemotherapy]
[note]
First-line chemotherapy for advanced (stage III or IV) epithelial ovarian, fallopian tube, and peritoneal cancer https://www.uptodate.com/contents/first-line-chemotherapy-for-advanced-stage-iii-or-iv-epithelial-ovarian-fallopian-tube-and-peritoneal-cancer
{not completed}
He was admitted for hemoptysis with blood clot from oral and nasal cavity for more than a week. History of NPC and CT imaging revealed possible tumor recurrence in Jan 2022.
[exam findings]
[consultation]
2023-03-17 Ear Nose Throat
2023-03-17 Infectious Disease
surgical operation
[drug identification]
The medication you are requesting drug identification for is Eltroxin, which contains levothyroxine at a dose of 0.05mg.
This medication is used to treat hypothyroidism, a condition where the thyroid gland does not produce enough thyroid hormone.
The medication will be sent back to the ward by an in-hospital porter.
[diagnosis] - 2023-03-17 admission note
[exam findings]
[consultation]
[surgical operation]
[C/T history]
C1D1 (#1) HD-MTX (8000mg/m2) on 2022/7/14, C1D2 Leucovorin (100 mg/m2) q6h until serum methotrexate <0.05 mmol/L and C1D3 Mabthera (375mg/m2) = 750mg on 2022/7/16. Rolican + HS hydration for AKI correct after HD-MTX. Feburic 80mg/tab (Febuxostat) 1# qod for prevent elevated uric acid.
C1D14 (#2) HD-MTX (due to AKI history, so change to 4000mg/m2) on 22022/8/09, Leucovorin 100mg q6h, Mabthera on 2022/8/11. Colchine and dexamethaxone for gouty arthritis treatment on 2022/8/17.
C2D1 (#3) HD-MTX (4g/m2), Covorin, Mabthera on 2022/8/24-8/26. C2D14(#4) HD-MTX (4g/m2), Covorin, Mabthera on 2022/9/12-9/14. C3D1 (#5) HD-MTX (4g/m2), Covorin, Mabthera on 2022/9/26-9/28.
2022/10/13 brain MRI: 1. Known a case of primary brain lymphoma. As compared with prior MRI (2022/06/20), marked shrinkage of left thalamus lesion (from 29mm to 12mm). But marked progression of lateral lesions (abutting left occipital horn) (from 15mm to 31mm). 2. Prominent peri-tumoral edema over left thalams and temporal lobe. C3D15 (#6) HD-MTX (8g/m2), Covorin, Mabthera on 2022/10/21-23.
He received the radiotherapy on 2022/11/2 -2022/12/6 with 3060cGy/17 fractions ofthe whole brain, and 4500cGy/25 fractions of the CNS lymphoma area.
C4D1 (#7) HD-MTX (8g/m2), Covorin,Mabthera on 2023/1/6-8. Followed up MRI of brain was performed on 2023/2/8 revealed No brain infarct was seen. Marked shrinkage of left thalamus and left occipital lesion. Marked regression of peri-tumoral edema.
This time, he was admitted for C4D15 (#8) chemotherapy HD MTX/Covorin/Mabthera on 2023/3/17.
[chemoimmunotherapy]
[dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL] D1 + [dexamethasone 4mg + diphenhydramine 30mg + acetaminophen 500mg + NS 250mL] D2
2022-10-21 - methotrexate 8000mg/m2 16000mg 6hr D1 + rituximab 375mg/m2 745mg 8hr D3
2022-09-26 - methotrexate 4000mg/m2 7950mg 6hr D1 + rituximab 375mg/m2 745mg 8hr D3
2022-09-12 - methotrexate 4000mg/m2 7980mg 6hr D1 + rituximab 375mg/m2 748mg 8hr D3
2022-08-24 - methotrexate 4000mg/m2 7880mg 6hr D1 + rituximab 375mg/m2 740mg 8hr D3
2022-08-09 - methotrexate 4000mg/m2 7900mg 6hr D1 + rituximab 375mg/m2 744mg 8hr D3
2022-07-14 - methotrexate 8000mg/m2 16000mg 6hr D1 + rituximab 375mg/m2 750mg 8hr D3
[note]
methotrexate (https://www.uptodate.com/contents/methotrexate-drug-information 2022-07-20)
leucovorin (https://www.uptodate.com/contents/leucovorin-drug-information 2022-07-20)
Methotrexate induced acute renal failure is typically nonoliguric and is reversible in almost all cases. Plasma creatinine levels usually peak within the first week and return toward baseline levels within 1 to 3 weeks. The patient’s renal function is decreasing at a much slower rate over time, which is a positive sign that creatinine almost reaches its peak level.
The likelihood of MTX-induced renal dysfunction in patients receiving high dose MTX can be minimized (but not eliminated) by hydration both to maintain a high urine flow and to lower the concentration of MTX in the tubular fluid and by alkalinization of the urine to a pH above 7.0. Raising the urine pH from 5.0 to 7.0 increases the solubility of MTX 10-fold.
It is customary to begin the MTX infusion only after the urine pH is >= 7.0 and to maintain it in this range until plasma MTX levels have declined to less than 0.1 microM.
Urinary alkalinization is most easily accomplished by adding ampules of sodium bicarbonate to each liter of IV fluid hydration. This accomplishes both fluid hydration and urinary alkalinization. A typical choice is IV D5W with 100 to 150 mEq of sodium bicarbonate per liter, administered by continuous infusion at 125 to 150 mL/hour. A cation concentration of 80.5 mEq/L is roughly equivalent to one-half normal saline. The amount of bicarbonate in each liter and the IV fluid composition can then be modified according to the urine pH and serum sodium.
An alternative oral protocol for sodium bicarbonate can be started with 3000 mg (300mg/tab * 10 tablets) Q6H, and can be escalated the frequency to Q4H as needed; once the urine pH is greater than 7, the 24 hour daily dose can then be lowered and divided into four doses, every six hours.
Lab data indicated that the patient’s renal function is deterioating
In this male patient, who is 56 y/o, Cre 2.02 mg/dL and weighs 82 kg, the estimated CrCl is 47 mL/min. The self-carried Baraclude (entecavir) for patients with CrCl 30 to <50 mL/minute: Administer 50% of usual indication-specific dose daily. Alternatively, administer the usual indication-specific dose every 48 hours. QODAC is preferred.
Methotrexate is greater 80% excreted as the unchanged drug and is primarily excreted in the urine. Leucovorin 100mg IVD Q6H has been administered since 2023-01-08 06:05.
Serum MTX levels are declining at an apparent rate.
If the patient is still able to urinate normally, furosemide may be an option for helping the excretion of methotrexate. For patients with an eGFR greater than 30 mL/minute/1.73m2, furosemide does not require dosage adjustment.
[lab data]
2023-03-17 Anti-HBc Nonreactive
2023-03-17 Anti-HBc-Value 0.18 S/CO
2023-03-17 Anti-HCV Nonreactive
2023-03-17 Anti-HCV Value 0.17 S/CO
2023-02-03 Anti-HCV Nonreactive
2023-02-03 Anti-HCV Value 0.10 S/CO
2023-02-03 HBsAg Nonreactive
2023-02-03 HBsAg (Value) 0.49 S/CO
2023-02-03 Anti-HBs 1.12 mIU/mL
2023-02-02 MTBC PCR NOT DETECTED
2023-02-02 MTBC PCR Value <11.8 CFU/ml
[exam findings]
[radiotherapy]
[chemotherapy]
[drug interaction]
Histamine H2 Receptor Antagonists may decrease the absorption of dasatinib. Dasatinib prescribing information states histamine H2 receptor antagonists (H2RAs) should not be coadministered with dasatinib due to the risk of reduced dasatinib concentrations and efficacy. Given the longer-term acid suppression achieved with H2-antagonist or proton pump inhibitor therapy, the manufacturer suggests the use of antacids (with 2-hour dose separation) if acid-reducing therapy is required. The likely mechanism for this apparent interaction is impaired absorption of dasatinib, which does appear to display pH-sensitive solubility, due to the increase in gastric pH caused by a H2-receptor antagonist.
Currently, the patient is prescribed Sprycel (dasatinib) and Ulstop (famotidine) with a QD and BID frequency, respectively. These medications are being administered at the same time of 09:00. To prevent any potential drug interactions, it is recommended to shift the administration time of one of the medications to a time that does not overlap with the other medication.
[exam findings]
[chemotherapy]
Granocyte (lenograstim 250ug/vial) CGRAN01 - 2023-03-02 ~ 2023-03-04 - 250ug QD SC - IPD 2023-03-02
[assessment]
{Malignant neoplasm of body of stomach; gastric antrum, pT4aN0M1, stage IV status post radical subtotal gastrectomy with lymph node dissection and B-II gastrojejunostomy}
[diagnosis] - 2023-02-04 discharge note
[past history]
[allergy]
[family history]
[exam findings]
[consultation]
[surgical operation]
[chemoimmunotherapy]
dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
2023-01-09 - oxaliplatin 70mg/m2 80mg 2hr + leucovorin 400mg/m2 450mg 2hr + fluorouracil 2400mg/m2 2760mg 46hr
2022-12-22 - oxaliplatin 70mg/m2 80mg 2hr + leucovorin 400mg/m2 470mg 2hr + fluorouracil 2400mg/m2 2840mg 46hr
2022-12-08 - oxaliplatin 70mg/m2 80mg 2hr + leucovorin 400mg/m2 450mg 2hr + fluorouracil 2400mg/m2 2760mg 46hr
2022-11-17 - oxaliplatin 40mg/m2 47mg 2hr + leucovorin 400mg/m2 470mg 2hr + fluorouracil 2000mg/m2 2360mg 46hr + [docetaxel 30mg/2 35mg IP 1hr + cisplatin 30mg/m2 35mg IP 1hr + gentamicin 40mg IP 1hr + sodium bicarbonate 2800mg IP 1hr]
2022-10-25 - oxaliplatin 40mg/m2 50mg 2hr + leucovorin 400mg/m2 470mg 2hr + fluorouracil 2000mg/m2 2370mg 46hr + [docetaxel 30mg/2 35mg IP 1hr + cisplatin 30mg/m2 35mg IP 1hr + gentamicin 40mg IP 1hr + sodium bicarbonate 2800mg IP 1hr]
2022-09-13 - oxaliplatin 40mg/m2 50mg 2hr + leucovorin 400mg/m2 490mg 2hr + fluorouracil 2000mg/m2 2470mg 46hr + [docetaxel 30mg/2 37mg IP 1hr + cisplatin 30mg/m2 37mg IP 1hr + gentamicin 40mg IP 1hr + sodium bicarbonate 2800mg IP 1hr]
2022-08-30 - oxaliplatin 40mg/m2 50mg 2hr + leucovorin 400mg/m2 490mg 2hr + fluorouracil 2000mg/m2 2470mg 46hr + [docetaxel 30mg/2 37mg IP 1hr + cisplatin 30mg/m2 37mg IP 1hr + gentamicin 40mg IP 1hr + sodium bicarbonate 2800mg IP 1hr]
2022-08-08 - mitomycin-C 15mg/m2 20mg 2hr D2-3 + [fluorouracil 500mg/m2 645mg IP 1hr D1-5 + gentamicin 40mg IP 1hr D1-5 + sodium bicarbonate 2800mg IP 1hr D1-5]
According to available lab data since 2022-07-05 in HIS5, the patient has experienced frequent occurrences of hyponatremia, hypopotassemia, hypokalemia, and hypomagnesemia. However, during the same time frame, there have been few instances of hyper- or hypophosphatemia.
The patient began receiving FOLFOX treatment in August 2022, and the use of carboplatin in this treatment regimen can be associated with hyponatremia, hypokalemia, hypomagnesemia, and hypocalcemia.
It is recommended to continue monitoring the patient’s electrolyte levels and prescribe supplements as needed. If it becomes challenging to maintain a balance of electrolytes through supplementation, it may be necessary to consider reducing the dose of carboplatin or switching to a different regimen.
As multiple body fluid (primarily ascites) cytological studies (2022-11-18, -11-17, -10-27, -10-26, -10-04, -09-14, -09-13, -09-01, -08-30) did not reveal evidence of malignancy, intraperitoneal chemotherapy was discontinued while systemic FOLFOX is continued.
The lab serum magnesium levels indicated a frequent deficiency of serum magnesium in this patient.
For the magnesium sulfate prescription will expire on the weekend, a lab data renewal may assist in determining whether the magnesium supplement should continue to be administered.
Body weight has decreased by almost 10 kg in the last 3 months (33.1kg 2022-10-25 <- 42.8kg 2022-07-27 gastrectomized), and a low albumin level (3.2 g/dL 2022-10-25) could indicate malnutrition. Long-term survival may be adversely affected by malnutrition after gastrectomy for gastric cancer (ref: Impact of Malnutrition After Gastrectomy for Gastric Cancer on Long-Term Survival. Ann Surg Oncol. 2018;25(4):974-983. doi:10.1245/s10434-018-6342-8)
It is advisable to begin strict nutritional follow-up as soon as possible after surgery in order to prevent a sharp weight loss in the early postoperative phase when most of the dietary problems arise.
Vitamin B12 injections might be required, as well as multivitamins and minerals.
As this patient’s weight is approximately equivalent to that of a ten-year-old child, the dosage might need to be adjusted accordingly.
[diagnosis]
[past history]
[exam findings]
[consultation]
[radiotherapy]
s/p palliative RT on 2022/06/07 (RUQ tumor), 2022/07/18 (left hilum), 2022/08/05 (left hilum), 2022/10/21 (liver, SBRT), 2023/01/02 (LUL).
[immunotherapy]
Advanced uterine leiomyosarcoma (ULMS) remains an incurable disease in most cases, and despite new drug approvals, improvements in overall survival have been modest at best. Microsatellite instability and/or high tumor mutational burden are distinctly uncommon in uterine LMS, perhaps explaining the lack of activity of immunotherapy agents observed in phase II trials in LMS.
Based on the available lab data in HIS5 since 2020-09-09, the patient’s HGB level has never reached the lower limit of normal. In 2023, the patient has received her 7th blood transfusion during this hospitalization.
There is no medication reconciliation issue found in the patient.
[tube feeding]
{not completed}
{angioimmunoblastic T cell lymphoma, high grade with neck, inguinal, retroperitoneal LN metastases and generalized skin rashes, Lugano stage III, PS:0}
[lab data]
[exam findings]
[chemoimmunotherapy]
[family meeting minutes]
In the family meeting, the attending physician Dr. Gao explained the process and precautions of autoPBSCT to the patient and his family members (sister and brother-in-law). The patient expressed his willingness to fully cooperate. However, the patient has been married before and his only daughter is currently studying in the United States and is unaware of her father’s medical condition.
The patient’s family support may be insufficient before and after the scheduled transplantation. The nursing station will assist in coordinating caregiver arrangements. The attending physician reminded the patient to inform his daughter about his condition, and the patient indicated his understanding.
[diagnosis] - 2023-03-13 admission note
[past history]
Medical history: HTN, Chronic rhinosinusitis
Operation history: - glaucoma - s/p Parotidectomy, left、submandibular gland tumor excision, left - s/p Port-A insertion, L’t after L’t cephalic vein exploration
[allergy]
[family history]
Denied family history
[exam findings]
[chemoimmunotherapy]
[assessment]
[diagnosis] - 20221219 admission note
[exam findings]
[surgical operation]
[chemotherapy]
Based on the available lab data, serum Ca levels are stably lower than the normal range. If PTH secretion is insufficient to act on kidney, bone, and intestines, hypocalcemia may occur (hypoparathyroidism). No PTH lab data available. As the serum albumin concentration is also below normal, the low calcium level could also be due to a reduction in serum albumin levels.
Even when potassium supplements are taken intermittently, serum K readings remain below normal range since December 2022. An acute increase in hematopoietic cell production is associated with potassium uptake by the new cells and this may lead to hypokalemia. Administration of vitamin B12 or folic acid to treat a megaloblastic anemia or use of granulocyte-macrophage colony-stimulating factor (GM-CSF) to treat neutropenia are the most common scenarios in which this occurs.
[diagnosis] - 2023-03-12 admission note
[edu opinion] - 2023-03-12 admission note
History - Orbital lymphoma more commonly presents in the middle-age and the elderly. - Slowly progressing, and typically painless.
Signs - Conj: the typical lesion is salmon or flesh-pink color - Orbit, eyelid: when palpable, the masses are firm. - Lacrimal gland: an “S-shaped” mass due to the lateral location of the lacrimal gland - Proptosis - Ptosis and decreased levator function may indicate superior orbital and levator muscle involvement, and motility should also be measured if the patient complains of diplopia. - Signs are more commonly unilateral
Symptoms - Many lesions are asymptomatic but depending on the location of the mass, patients can complaint of exophthalmos, pain or diplopia, as well of conjunctival, eyelid, orbital or lacrimal gland mass.
Differential diagnosis - Benign lymphoproliferative lesions - Lymphoid hyperplasia - Systemic lymphoma - Metastasis - Amelanotic melanoma - Epithelial tumors - Inflammatory and infectious lesions - Orbital pseudotumor - Cavernous hemangioma
[past history]
[allergy]
[exam findings]
(145 - 47) / 145 - M-mode (Teichholz) = 68 - Prominent concentric LV hypertrophy and mild RV hypertrophy with indeterminated LV filling pressure and impaired RV relaxation; moderately dilated LA. - Dilated LV with normal LV and RV systolic function. - Aortic valve sclerosis and mild aortic root calcification; mild MR; mild PR.
[consultation]
[chemoimmunotherapy]
[assessment]
[exam findings]
[consultation]
[surgical operation]
[chemotherapy]
The WBC count reached its lowest point approximately 7-10 days after the previous chemotherapy treatment in this patient, as indicated by the time relationship between the chemotherapy dates and the lab data recorded at this hospital.
Epirubicin can cause neutropenia (in 54% to 80% of patients; with grades 3/4 in 11% to 67%; nadir occurring at 10 to 14 days and recovery by day 21) and leukopenia (in 50% to 80% of patients; with grades 3/4 in 2% to 59%). ref: UpToDate
The prophylactic administration of G-CSF after chemotherapy may be considered around one week after treatment. Another option to consider is to moderately reduce the dose of epirubicin.
Cyclophosphamide use may lead to hemorrhagic cystitis, which can cause pyelitis, ureteral disease (ureteritis), and hematuria. Therefore, please closely monitor for any signs of these possible adverse reactions. Mesna can be used for the prevention of cyclophosphamide-induced hemorrhagic cystitis in cancer patients. Patients who have difficulty emptying their bladders are at a higher risk of developing bladder toxicity. If there is a clinical concern, a bladder ultrasound should be performed, and if there is a high post-void residual, the use of mesna is also appropriate for such patients.
[exam findings]
[consultation]
[chemoimmunotherapy]
diphenhydramine 30mg + granisetron 1mg diphenhydramine 30mg + granisetron 1mg diphenhydramine 30mg + granisetron 1mg diphenhydramine 30mg [assessment - appetite stimulant]
The patient reached his lowest recorded weight of 52.6kg on 2023-01-13, before slightly increasing to 54.6kg on 2023-02-24. The patient is currently receiving nutrition through a nasogastric tube and it is recommended to provide sufficient calories, protein, and other nutrients.
Previously in another pharmacist note, megestrol was recommended as an appetite stimulant, but if the patient cannot tolerate it and there is still a need for an appetite stimulant, Pilian (cyproheptadine 4mg/tab) might be also considered as an off-label alternative for decreased appetite due to chronic disease. The recommended dosage for Pilian is an initial 2mg four times per day for one week, followed by 4mg four times per day.
Quetiapine might then be considered as a last resort to increase weight, but it comes with the cost of dyslipidemia.
[assessment - pain control]
MXL (morphine 60mg/cap) 1# Q12H, fentanyl transdermal patch 50ug/h 2# Q3D, OxyNorm (oxycodone 5mg/cap) 2# Q4H have been properly prescirbed to deal with the backgroud pain.
NG tube OxyNorm administration: pour the small granules out of the OxyNorm capsules, dissolve them in drinking water, and pass them through the feeding tube.
If the patient still experiences breakthrough pain with a high VAS score, the addition of PRN morphine might be considered.
HGB 11.3 g/dL 2023-02-09 <- 6.5 g/dL 2023-02-06, in this case, anemia has been mitigated.
Platin- and taxel-based treatments have been administered to the patient.
2020 ASCO guidelines suggest that clinicians may offer duloxetine to patients with chemotherapy-induced peripheral neuropathy, and 2020 joint ESMO/EONS/EANO guidelines recommend duloxetine for treatment of neuropathic pain in this setting. ref: Prevention and Management of Chemotherapy-Induced Peripheral Neuropathy in Survivors of Adult Cancers: ASCO Guideline Update. J Clin Oncol 2020; 38:3325. https://doi.org/10.1200/jco.20.01399
The platinum agents cisplatin and carboplatin are used both as single agents and to form the backbone for most combination regimens to treat metastatic and recurrent head and neck cancers. Although carboplatin is often considered to be less systemically effective than cisplatin in head and neck cancer, there is little direct evidence. Carboplatin may be preferred in some cases since it is associated with less neurotoxicity, nephrotoxicity, ototoxicity, and nausea and vomiting compared with cisplatin, although carboplatin causes more myelosuppression.
[duplicate note]
Since the patient has lost more than 10kg of body weight over the past 5 months (64.4kg 2022-09-17 -> 52.6kg 2023-01-13), possibly as a result of tumor-induced cachexia, it is recommended that the patient consume more and/or receive more intensive nutritional support. The addition of some appetizers, such as megestrol, might be beneficial.
Metoclopramide has been prescribed. The use of Emend (aprepitant) for antiemetic effect might be considered if nausea and/or vomiting is observed.
[exam findings]
[consultation]
[exam findings]
[consultation]
[chemotherapy]
[assessment]
The patient’s renal function has declined, as evidenced by a decrease in creatinine clearance based on Cockcroft-Gault formula to 33mL/min as of 2023-03-06.
In patients with a CrCl between 25 and 50 mL/min, a recommended dose of 1g Q12H for meropenem is advised, compared to the intended dose of 1g Q8H.
By the way, there is no dosage adjustment necessary for any degree of kidney dysfunction for micafungin use. And there are no dosage adjustments for nystatin provided in the manufacturer’s labeling for patients with kidney Impairment.
{Squamous cell carcinoma of the L/3 esophagus, stage cT2N2M0 (stage IIIA), s/p CCRT, and s/p adjuvant chemotherapy, with local regional recurrence. Squamous cell carcinoma of the hypopharynx, p16 (+), stage cT2N2bM0.}
[lab data]
[exam findings]
[consultation]
[surgical operation]
[radiotherapy]
[chemoimmunotherapy]
[note]
2023-03-05 lab data CRP 5.25mg/dL.
2023-03-05 sputum gram’s stain result showed:
As the staining results may suggest a possibility of contamination, it may be necessary to collect a new sample.
Moxifloxacin with an antibacterial spectrum encompassing both aerobic gram-negative and gram-positive strains, as well as anaerobic bacteria, can be used for pneumonia, community-acquired, outpatients with comorbidities and inpatients as an alternative agent. It is not recommended to be used in patients with risk factors for P. aeruginosa (ATS/IDSA [Metlay 2019]; File 2020). Based on the normal liver and kidney function lab results on 2023-03-05, the current dosage of 400 mg once daily is appropriate and does not require any adjustments.
[tube feeding]
Broen-C (bromelain + L-cysteine) is an enteric-coated tablet designed to prevent the destruction of the bromelain enzyme by gastric juice.
Bromelain is sensitive to extreme conditions such as high temperature, gastric proteases in stomach juice, high acidity, and organic solvents, and thus, reduces its functionalities and bioavailability. Its instability under such stress conditions reduce its enzymatic activity, decrease its health benefits, and limit its pharmacological applications. ref: Mala T, Anal AK. Protection and Controlled Gastrointestinal Release of Bromelain by Encapsulating in Pectin-Resistant Starch Based Hydrogel Beads. Front Bioeng Biotechnol. 2021;9:757176. Published 2021 Oct 29. doi:10.3389/fbioe.2021.757176
There are no other drugs in the inventory that contain bromelain.
[tube feeding]
[tube feeding]
[tube feeding]
[tube feeding]
[exam findings]
[consultation]
[radiotherapy]
[chemoimmunotherapy]
[assessment]
Lab data
According to recent lab results, there is no longer leukopenia observed, but instead an overboosted WBC count accompanied by an elevated CRP reading (G-CSF administered on 2023-02-27). Please be aware of any signs of infection or inflammation. Anemia has gradually improved, and there is no observed thrombocytopenia.
The patient received injectable Amsulber (ampicillin + sulbactam) from 2023-02-23 to 2023-03-02 and has been taking oral Soonmelt (amoxicillin + clavulanic acid) since 2023-03-03. However, there has been no recent culture result available for the patient.
The laboratory results from 2023-02-28 also showed 4+ stool occult blood, which could be a possible cause of the anemia. It would be beneficial to rule out gastrointestinal bleeding before discharging the patient.
[exam findings]
[chemotherapy]
[assessment]
[exam findings]
[consultation]
[chemotherapy]
2023-03-01 - Vidaza (azacitidine) 75mg/m2 150mg SC D1-7
2023-02-02 - Vidaza (azacitidine) 75mg/m2 150mg SC D1-7
2021-05-17 ~ 2021-07-05 UFT (tegafur + uracil) KUFT01
[assessment]
Lab data
According to the lab data on 2023-03-01, leukopenia has improved in the patient. However, anemia is still progressing, and blood transfusion might be necessary.
Erythropoiesis-stimulating agents (ESAs) have been recommended as an effective treatment option for lower-risk MDS, including biosimilar epoetin alfa. ref: Epoetin alfa for the treatment of myelodysplastic syndrome-related anemia: A review of clinical data, clinical guidelines, and treatment protocols. Leuk Res. 2019;81:35-42. doi:10.1016/j.leukres.2019.03.006
In addition to leukopenia and anemia, the patient has been experiencing thrombocytopenia for years with no substantial improvement. Therefore, increased risk of bleeding should be carefully monitored and managed.
Thrombocytopenia is a significant problem in myelodysplastic syndromes (MDS) and acute myeloid leukemia (AML). Eltrombopag, a thrombopoietin receptor agonist, has shown potential clinical activity in MDS and AML clinical trials. Studies have shown that eltrombopag is well tolerated and clinically effective in both low-risk and higher-risk MDS and AML patients. ref: Eltrombopag reduces clinically relevant thrombocytopenic events in higher risk MDS and AML. Lancet Haematol. 2018;5(1):e6-e7. doi:10.1016/S2352-3026(17)30229-6
There was another study evaluated the safety and efficacy of Eltrombopag in low to intermediate risk myelodysplastic syndromes (MDS) patients. The primary efficacy endpoint was hematologic response at 16-20 weeks, and 44% of the patients responded. The safety profile was consistent with previous studies, and Eltrombopag was effective in restoring hematopoiesis in these patients. ref: Eltrombopag monotherapy can improve hematopoiesis in patients with low to intermediate risk-1 myelodysplastic syndrome. Haematologica. 2020;105(12):2785-2794. Published 2020 Dec 1. doi:10.3324/haematol.2020.249995
[diagnosis]
[exam findings]
[chemoimmunotherapy]
[assessment]
This patient with Small cell B-cell lymphoma was treated with a total of six cycles of R-COP regimen from 2021-10 to 2022-03. However, during regular CT follow-up on 2022-11-25, progression of lymphadenopathy was observed in the mesenteric and paraaortic regions. As a result, the patient was rechallenged with R-COP from 2022-12 onwards.
The lab results from 2023-03-01 indicated that there were no notable abnormalities in the patient’s liver and kidney functions or blood cell counts. And the TPR panel revealed that the patient’s vital signs and blood pressure were stable.
Entecavir is prescribed to suppress the replication of the hepatitis B virus with no issue.
[present illness] - 2023-02-27 admission note
[past history]
[allergy]
[family history]
[exam findings]
[chemoimmunotherapy]
[G-CSF]
[assessment]
It is recommended avoiding the administration of filgrastim from 24 hours before to 24 hours after the administration of cytotoxic chemotherapy, due to the potential sensitivity of rapidly dividing myeloid cells to the cytotoxic effects of chemotherapy.
Filgrastim was administered on 2023-02-27 and chemotherapy is scheduled to be administered on 2023-03-01, with one day in between. Our administration pattern for the patient helps to uphold this principle without an issue.
[exam findings]
[surgical operation]
[chemoimmunotherapy]
[assessment]
A blood transfusion may be considered in light of the patient’s HGB level of 8.6 g/dL, PLT count of 31K/uL, and 4+ stool occult blood in 2023-02-28 lab results.
The sputum culture result 2023-02-28 revealed the presence of 1+ gram-positive cocci and 2+ gram-negative bacilli. Levofloxacin has been prescribed appropriately to target and treat these strains.
[present illness]
[past history] - 2023-02-25 admission note
[allergy]
[family history]
[exam findings]
[medication]
[assessment]
Based on the patient’s medication history of erlotinib followed by afatinib, it can be inferred that the disease is likely positive for EGFR exon 19 deletion or L858R, S768I, L861Q, and/or G719X mutations.
The patient had Grade 1 diarrhea which responded well to Smecta treatment (bowel movement of 3 times each day on 2023-02-27 and 2023-02-28). Additionally, the patient also experienced Grade 2 dermatitis and onychomycosis, which are currently being treated externally with tetracycline. If severe or prolonged diarrhea is not responding to antidiarrheal agents, GILOTRIF should be withheld to prevent dehydration and renal failure. In addition, GILOTRIF should be discontinued for life-threatening cutaneous reactions. Severe bullous, blistering, and exfoliating lesions occurred in 0.2% of patients. Severe and prolonged cutaneous reactions also require withholding of GILOTRIF.
After ground glass opacity was detected in bilateral lower lungs on the chest X-ray 2023-02-25, and G(+) Cocci were identified from sputum culture 2023-02-26, the afatinib treatment was temporarily suspended until the lung symptoms were relieved.
The current prescription is without any issue.
[diagnosis] - 2023-02-23 admission note
[past history] - 2022-12-08 admission note
[lab data]
[exam findings]
[surgical operation]
[chemoimmunotherapy]
The most common sequelae, or aftereffects, of axillary lymph node dissection (ALND 2022-08-11) are arm lymphedema, numbness, and limited shoulder mobility.
For patients with lymphedema (ie, International Society of Lymphology - ISL stage I, II, III), there is a recommendation to measure blood pressure in the contralateral arm, particularly in any setting in which blood pressure is being closely repeatedly or continuously monitored.
The effectiveness of these treatments in patients with established breast cancer-associated lymphedema (BCAL) is summarized below.
This (2023-02-24) morning, there was a decrease in blood pressure by 10mmHg resulting in a reading of 96/57, which should be noted. If the blood pressure continues to decrease, the administration of Concor (bisoprolol 5mg) may be suspended.
No medication reconciliation issues were found during this hospital stay, and the recently prescribed drugs disclosed in the NHI PharmaCloud System have been accurately prescribed as self-carried items that cover the patient’s underlying conditions.
[exam findings]
[assessment]
Based on the available lab data in HIS5, the patient’s HGB level has been consistently below the lower limit of normal since May 2020. The most recent HGB level recorded on 2023-02-23 was 7.4g/dL. It is recommended to closely monitor the patient’s ability to oxygenate.
For patients with chronic kidney disease-related anemia (2023-02-07 Ferritin 731.6ng/mL), the initiation of epoetin alfa or its biosimilars is generally recommended when Hb levels fall below 10 g/L, according to the Kidney Disease: Improving Global Outcomes (KDIGO) Anemia Work Group. Reference: KDIGO clinical practice guideline for anemia in chronic kidney disease, published in Kidney Int Suppl in 2012;2(suppl):279-335.
Please evaluate if the detected bacteriuria (2023-02-24 lab result) indicates an asymptomatic UTI or not. Asymptomatic bacteriuria is common, but most patients with asymptomatic bacteriuria have no adverse consequences and derive no benefit from antibiotic therapy. With few exceptions, nonpregnant patients should not be screened or treated for asymptomatic bacteriuria.
{not completed}
[diagnosis]
[past history]
[allergy]
[family history]
[exam findings]
[consultation]
[radiotherapy]
[chemoimmunotherapy]
2023-02-23 - ramucirumab 8mg/kg 400mg NS 250mL 1hr + oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2800mg/m2 4560mg NS 500mL 46hr (Cyramza + FOLFOX, Q2WK)
2023-02-03 - ramucirumab 8mg/kg 500mg NS 250mL 1hr + oxaliplatin 85mg/m2 145mg D5W 250mL 2hr + leucovorin 400mg/m2 684mg NS 250mL 2hr + fluorouracil 2800mg/m2 4800mg NS 500mL 46hr
2023-01-15 - ramucirumab 8mg/kg 500mg NS 250mL 1hr + oxaliplatin 85mg/m2 145mg D5W 250mL 2hr + leucovorin 400mg/m2 684mg NS 250mL 2hr + fluorouracil 2800mg/m2 4800mg NS 500mL 46hr
2022-12-30 - ramucirumab 8mg/kg 500mg NS 250mL 1hr + oxaliplatin 85mg/m2 145mg D5W 250mL 2hr + leucovorin 400mg/m2 684mg NS 250mL 2hr + fluorouracil 2800mg/m2 4800mg NS 500mL 46hr
2022-12-16 - ramucirumab 8mg/kg 500mg NS 250mL 1hr + oxaliplatin 85mg/m2 145mg D5W 250mL 2hr + leucovorin 400mg/m2 684mg NS 250mL 2hr + fluorouracil 2800mg/m2 4800mg NS 500mL 46hr
2022-06-13 - irinotecan 180mg/m2 290mg D5W 250mL 90min + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2800mg/m2 4680mg NS 500mL 46hr
… … ..
2022-03-08 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 300mg D5W 250mL 90min + leucovorin 400mg/m2 670mg NS 250mL 2hr + fluorouracil 2800mg/m2 4680mg NS 500mL 46hr (Avastin + FOLFIRI, Q2WK)
… … ..
2021-06-11 - irinotecan 180mg/m2 310mg D5W 250mL 90min + leucovorin 400mg/m2 690mg NS 250mL 2hr + fluorouracil 2800mg/m2 4830mg NS 500mL 46hr
There is a possible trend towards leukopenia as the patient’s WBC count has gradually decreased over time.
The patient’s HbA1c levels have slowly increased and warrant attention.
Diarrhea seems to have improved as there was no bowel movement recorded on 2023-02-23.
The medications recently prescribed for the patient are in accordance with the records in the NHI PharmaCloud System, and have been correctly prescribed as self-carried items during this hospital stay to cover his underlying conditions. No issues related to medication reconciliation have been identified.
[past history]
Medical history:
Surgical: operation for endometriosis x3, 10+ years ago (open abdominal x1 + hysteroscopic x2)
Menstrual history: G0P0, Last menstrual period:2022/8/2
Has regular Pap smear examination (most recent 2022/08/03)
[allergy]
[family history]
[exam findings]
[surgical operation]
[chemoimmunotherapy]
[past history] - 2023-02-22 admission note
[allergy]
[family history]
[lab data]
[exam findings]
[SOAP]
[chemotherapy]
[assessment]
The use of 5-fluorouracil/mitomycin or capecitabine/mitomycin in combination with radiation for the treatment of anal cancer was considered (2023-02-10). A population-based study found that capecitabine/mitomycin and fluorouracil/mitomycin given concurrently with radiation achieved similar disease-free survival (DFS) and anal cancer-specific survival (ACSS). As such, substituting capecitabine for infusional 5-FU may be a viable option for patients and healthcare providers who prefer to avoid the potential complications and inconvenience of a central infusional device. (Reference: “A comparison between 5-fluorouracil/mitomycin and capecitabine/mitomycin in combination with radiation for anal cancer.” J Gastrointest Oncol. 2016;7(4):665-672. doi:10.21037/jgo.2016.06.04)
The mitomycin and fluorouracil with concurrent radiation (FUMIR) regimen was ultimately chosen for the patient. There are multiple variations of this regimen. The standard administration of 5-FU involves a continuous infusion over 4 days, specifically on Day 1-4 and 29-32. (ref: Mitomycin and Fluorouracil With Concurrent Radiation (FUMIR) Regimen for Anal Cancer. Hosp Pharm. 2013;48(6):464-469. doi:10.1310/hpj4806-464). Due to the patient’s advanced age, a 3-day infusion was utilized during this hospitalization, with a weekend break in between.
Lab results 2023-02-22 revealed that the CBC, WBC DC, Na, K, liver and kidney function were grossly normal, indicating no significant abnormalities.
In the review of systems section of the admission note (2023-02-22, yesterday), it was documented that the patient had been experiencing constipation for a period of two months, as well as anal bleeding with pain. The prescription of sennoside has been appropriately made. If anal bleeding persists, the addition of tranexamic acid may be considered as a potential treatment option.
A summary of the compatibility of mitomycin with various intravenous solutions is listed as following: mitomycin is not compatible with D5W, Dextrose 3.3% in sodium chloride 0.3%, and Dextrose 5% in water. Compatibility with D10W, D5LR, D5NS, 1/2NS, D5W-1/2NS and Ringer’s Injection is untested. IV compatibility with Normal saline (Sodium chloride 0.9%) is variable; Lactated Ringer’s Injection, Sodium chloride 0.4%, Sodium chloride 0.6%, and Sodium lactate 1/6 M is compatible.
This patient passed away at 10:19, 2022-11-03.
[lab data]
2023-06-26 CMV viral load assay Target not detecetedIU/mL
2023-06-19 CMV viral load assay Target not detecetedIU/mL
2023-06-12 CMV viral load assay Target not detecetedIU/mL
2023-03-14 CMV IgM Nonreactive
2023-03-14 CMV IgM Value 0.57 Index
2023-03-14 CMV_IgG Reactive
2023-03-14 CMV_IgG Value 393.8 AU/mL
2023-02-16 FLT3-D835 Undetectable
2023-02-15 BCR/abl Undetectable
2023-02-15 PML-RARA Undetectable
2023-02-13 FLT3/ITD Undetectable
2023-02-13 NPM1 Undetectable
2023-02-04 Anti-HBc Nonreactive
2023-02-04 Anti-HBc-Value 0.21 S/CO
2023-02-04 Anti-HBs 1.78 mIU/mL
2023-02-04 Anti-HCV Nonreactive
2023-02-04 Anti-HCV Value 0.09 S/CO
2023-02-04 HBsAg Nonreactive
2023-02-04 HBsAg (Value) 0.36 S/CO
2023-02-04 Anti-HBc IgM Nonreactive
2023-02-04 Anti-HBc IgM Value 0.10 S/CO
[exam findings]
[MedRec]
[consultation]
[chemotherapy]
CYTARABINE (ARA-C) HIGH DOSE - Consolidation chemotherapy for AML in remission — https://nssg.oxford-haematology.org.uk/myeloid/protocols/ML-4-cytarabine-ara-c-3g-m2.pdf
ACUTE MYELOID LEUKAEMIA - CYTARABINE (3000mg/m2) — https://www.uhs.nhs.uk/Media/UHS-website-2019/Docs/Chemotherapy-SOPs1/AML/Cytarabine3000.pdf
{DLBCL}
[diagnosis] - 2022-07-31 discharge diagnosis
[lab data]
[exam findings]
[consultation]
[chemoimmunotherapy]
[exam findings]
[consultation]
[chemotherapy]
[tube feeding]
Keppra: In this hospital, there is a liquid form of Keppra oral solution (levetiracetam 100mg/mL, 300mL per bottle) that is suitable for tube feeding.
OxyNorm: Pour the small granules out of the OxyNorm (oxycodone 5mg/cap) capsules, dissolve them in drinking water, and administer them through a tube feeding.
OxyContin: OxyContin (oxycodone 10mg controlled-release tablet) is a long-acting formulation. Grinding the tablet will destroy the controlled-release design and cannot maintain long-lasting effects. Its use is not recommended for tube feeding.
[drug interaction]
Morphine (8mg IVD PRNQ6H currently) is contraindicated when used concurrently with monoamine oxidase inhibitors (MAOIs, linezolid 600mg IVD Q12H currently).
There is a possibility that monoamine oxidase inhibitors may enhance the adverse/toxic effects of morphine. Please monitor any possible adverse reactions carefully.
[diagnosis] - 2023-01-16 admission note
[past history]
[allergy]
[family history]
[lab data]
[exam findings]
[consultation]
[surgical operation]
[radiotherapy]
[assessment]
Except for urticaria, the underlying conditions listed in the problem list are appropriately treated with corresponding medications.
As a premedication, a single shot diphenhydramine is used in the current chemotherapy regimen, however, the newer, second generation H1 antihistamines are recommended as first-line therapy for urticaria. These newer drugs are minimally sedating, are essentially free of the anticholinergic effects that can complicate use of 1st generation agents, have few significant drug-drug interactions, and require less frequent dosing compared with first-generation agents. It is recommended to initialize a 2nd generation antihistamine at standard therapeutic dose:
{not completed}
[exam findings]
2023-02-08, -02-05, -01-31 CXR
2023-02-05 CT - brain
2023-02-03 MRI - brain
2023-02-03 Electroencephalography, EEG
2023-02-03 Peripheral Vascular Test - vein, lower limbs
…
…
…
lab data
surgical operation
radiotherapy
chemoimmunotherapy
2023-01-23 urine culture found Candidas abicans 50000 colony count CFU/cc. Treatment of candidemia and invasive candidiasis in nonneutropenic patients could be an echinocandin (1. caspofungin 70 mg IV loading dose, then 50 mg IV daily; 2. micafungin 100 mg IV daily; 3. anidulafungin 200 mg IV loading dose, then 100 mg IV daily. Items 2 and 3 are not necessary to be dose adjusted for any degree of kidney impairment and they are available in this hospital.) is recommended as initial therapy. (ref: https://www.uptodate.com/contents/image?imageKey=ID%2F87676)
2023-01-13 anaerobic culture of the perineuim was found to contain Bacteroides thetaiotaomicron 3+ that was sensitive to metronidazole and ampicillin/sulbactam. It is not necessary to adjust dose for metronidazole if CrCl is greater than 10, while for ampicillin/sulbactam, CrCl is greater than 30. Keep metronidazole use is recommended.
If Keppra (500mg Q12H) is not demonstrated to be effective for seizure control, valproate (no dosage adjustment necessary if CrCl >= 10 mL/min) or carbamazepine (no dosage adjustment necessary for kidney impairment) might be added.
[compatible solutions to mitigate hypernatremia that do not rely on saline]
Following is a list of the selected injectable medications in the active prescription and their compatibility with non-saline-based solutions according to MicroMedex.
Use potassium supplements if necessary
WBC returned to 5.05K/uL on 2023-02-12, neutropenia not observed.
[diagnosis] - 2022-12-02 admission note
[past history]
[family history]
[exam findings]
[consultation]
[surgical operation]
[chemoimmunotherapy]
[exam findings]
[chemotherapy]
[assessment]
[diagnosis] - 20230203 admission note
[past history]
[allergy]
[exam findings]
[consultation]
[chemotherapy]
[medication]
{not completed}
[exam findings]
[diagnosis] - 2023-01-12 discharge note
[Past History]
[Family History]
[lab data]
[exam findings]
[surgical operation]
[radiotherapy]
[chemotherapy]
[assessment]
[potential drug interactions]
Flunarizine (patient-carried) is cocommitant with clonazepam, diphenhydramine, estazolam and fexofenadine currently.
According to the flunarizine product monograph (https://www.aapharma.ca/downloads/en/PIL/2021/Flunarizine_PM_EN.pdf), use of CNS depressants, including alcohol, should be avoided during treatment with flunarizine due to the risk of excessive sedation.
There is also an antivertigo preparation available in stock known as Nilasen (betahistine 24mg/tab), which has a lower risk of drug interaction than flunarizine and can be considered as a 1# daily dosage alternative.
There is no specific pharmacist shift handover to follow in this patient.
[drug identification]
[diagnosis] - 2023-02-01 discharge note
[lab data]
[exam findings]
[consultation]
[surgical operation]
[radiotherapy]
[chemotherapy]
[diagnosis] - 2023-02-01 discharge note
[lab data]
[exam findings]
[surgical operation]
[radiotherapy]
[chemotherapy]
[diagnosis] - 2022-10-01 discharge
[exam findings]
[consultation]
[surgical operation]
[radiotherapy]
[chemoimmunotherapy]
Esophageal and Esophagogastric Junction Cancers, NCCN Evidence Blocks, 2022-09-07, Version 4.2022, ESOPH-F 5 OF 17, p49 = Principles of Systemic Therapy > Regimens and Dosing Schedules > Other Recommended Regimens
Administration
[assessment]
In response to anemia (2023-01-27 HGB 7.5g/dL), LPRBC 2U was transfused on 2023-01-28 to treat the condition.
Cold hemagglutination was observed in 2023-01-27 lab data.
[exam findings]
[assessment]
Despite having a pacemaker implanted, the patient’s heart rate doubled from 64 (2023-01-29 20:03) to 144 (2023-01-30 08:50).
Runaway pacemaker occurs when the pacemaker’s pulse generator discharges at a rate above its preset upper limit. The malfunction lies entirely within the pulse generator. It should be suspected if pacemaker dysrhythmias occur at rates greater than 130 beats/min or the upper rate limit if this is known. ref: Tachycardia in the presence of a pacemaker. Postgrad Med J. 2004;80(940):119-122. doi:10.1136/pmj.2002.004036q
[lab data]
[exam findings]
[consultation]
[surgical operation]
[radiotherapy]
[chemoimmunotherapy]
When pulmonary symptoms limit the patient’s ventilation, oxygenation becomes more important.
Laboratory 2023-01-28: MCV 68.5fL, MCH 21.5pg, both below LLN since 2nd half 2022, there may be an iron deficiency. It is recommended that the patient’s body iron level be checked in order to determine whether iron supplements need to be added.
[tube feeding, drug interactions]
Scrat (sucralfate) should be administered on an empty stomach. Please shake suspension well before use and do not administer antacids within 30 minutes of administration of sucralfate. In general, it is recommended to separate administration of other oral medications and sucralfate by at least 2 hours. With Panzolec (pantoprazole) 40mg IVD QD (09:00) and Scrat 1g PO Q6H (05:00, 11:00, 17:00, 23:00), it should be less likely that there will be obvious interactions between the two. The adjustment does not need to be made.
Bromelain, the main active ingredient in Broen-C tablets, is sensitive to extreme conditions such as high temperature, gastric proteases in stomach juice, high acidity, and organic solvents, and thus, reduces its functionalities and bioavailability. Its instability under such stress conditions reduce its enzymatic activity, decrease its health benefits, and limit its pharmacological applications. The drug is therefore designed to be enteric coated. There is no alternative for this ingredient available in the hospital at present time.
Management of vasogenic edema in patients with primary and metastatic brain tumors - glucocorticoids - ref: https://www.uptodate.com/contents/management-of-vasogenic-edema-in-patients-with-primary-and-metastatic-brain-tumors
2023-01-11 brain MRI showed increased heterogeneous soft tissue enhacement in the right temporal lobe and right cavernous sinus with right cavernous ICA encasement. suspected radiation necrosis or tumors.
Systemic glucocorticoids are the mainstay of symptomatic therapy for peritumoral edema. They play a role in stabilizing patients awaiting definitive treatment of the tumor as well as in palliative management of edema related to treatment-refractory tumors.
Emergency management of increased ICP
Initiation of glucocorticoids
Dexamethasone dose and schedule
Response assessment
Inadequate response to initial dose
Approach to taper
Refractory edema
Symptomatic plateau waves
{drug interactions}
[exam findings]
[tube feeding]
Harnalidge (tamsulosin, designed for extended release) 0.4mg PO QDAC should be replaced by Urief (silodosin) 8mg PO QD for tube feeding.
Concor (bisoprolol 5mg/tab) package insert recommends swallowing the medication with some liquid and not chewing it. For tube feeding, the simple suspension method (SSM) involves suspending tablets and capsules in warm water for decay and suspension prior to administration, which can be applied to the Concor tablets.
{High grade B-cell lymphoma with left aspect of mandible, multiple lymph nodes in the abdomen and the regions about the pericardium and pleura of left lower lung field, Lugano stage IV, IPI score:3, High-intermediate risk group, PS:1}
In late October 2022 and mid-Jan 2023, grade 4 neutropenia occurred approximately between 1-2 weeks after the patient’s receiving R-CHOP. As soon as neutropenia is identified, filgrastim and/or lenogastin has been appropriatedly administered. The WBC count returned to 1440 cells/uL on 2023-01-16.
Following a peak of 220mg/dL (2023-01-14 17:00), the patient’s serum glucose level returned to 114mg/dL (2023-01-16 05:17). It is not necessary to modify the patient’s antihyperglycemic agent immediately.
To treat neutropenic fever in this patient with hematologic malignancy, it is recommended to initialize an antipseudomonal beta-lactam agent, such as cefepime, meropenem, imipenem, or piperacillin-tazobactam. Since 2023-01-13, cefepime 2000mg IVD Q8H has been used.
Since the culture result has not been released, teicoplanin 600 mg IVD QD and fluconazole 300 mg PO QD have also been added in order to broaden the scope of coverage.
Based on 2023-01-13, 15, 16 lab data, there is no evidence that the patient’s liver or kidney function has declined. Therefore, no dose adjustment is required for the medication prescribed.
Cimetidine may increase the serum concentration of metformin. The AUC of metformin increased 40% when combined with a single dose of cimetidine (400 mg) and increased 50% after treatment with cimetidine (400 mg twice daily) for 5 days in healthy volunteers. In an another study of 15 healthy volunteers, cimetidine administration decreased metformin renal tubular clearance by 18.7% to 48.2%, depending on the individual’s organic cation transporter 2 (OCT2) genotype. Participants carrying the OCT2 808G>T polymorphism had lower baseline tubular clearance of metformin and a correspondingly lower magnitude of interaction with cimetidine.
As the patient’s renal function still works (2023-01-05 Cre 1.08mg/dL, eGFR 53, BUN 14mg/dL), it is less likely to develop lactic acidosis, however, close monitoring might be necessary.
The historical time series lab data suggest that the roughly cyclic trough WBC level (neutropenia events) was frequently observed around 3 weeks following each R-CHOP treatment. It might be necessary to plan in advance for the possible neutropenia 3 weeks after this hospital stay in order to ensure the G-CSF is accessible to the patient during the Chinese New Year long holidays.
Diagnosed T2DM. Glucose One Touch data: 228 (2022-08-31 17:05), 203 (2022-09-01 06:09), 256 (2022-09-01 11:12). No HbA1c records found.
This patient is taking self-carried gliclazide 15mg QD and metformin 500mg TIDCC.
Suggestion:
{poorly differentiated squamous cell carcinoma of esophagu, cT3N2M0 stage III; poorly differentiated adenocarcinoma of stomach with liver metastases, cT3N0M1, stage IV}
Anemia can be classified based on whether the MCV is low, normal, or elevated. A decreased MCV (usually less than 80 fL) indicates a defect in the synthesis of hemoglobin, which may be caused by an iron deficiency. And the presence of an increased MCV (>100 fL) is often attributed to asynchronous maturation of nuclear chromatin, although other factors may also contribute.
A low MCH is typically reflected in an enlarged area of central pallor in RBCs on the peripheral blood smear, which defines “hypochromia” on the blood smear. This may be seen in iron deficiency and thalassemia.
Very low MCHC values are typical of iron deficiency anemia, and very high MCHC values typically reflect spherocytosis or RBC agglutination.
[assessment]
[assessment]
[tube feeding]
Current administration routes are IVD and TPN; there is no tube feeding at this time.
{not completed}
[duplicate note]
[assessment]
As of 2023-01-10, WBC is 2.87K/uL, neutrophil is 53%, and ANC is greater than 1500 cells/uL.
However, there is a trend downward in WBC count which should be noted.
{Recurrent left breast cancer with bilateral lung, right pleura, liver, bone and lymph node metastases, rcTxN2M1, stage IV}
[note]
{colon cancer with lung and liver metastases, T4aN2bM1b, stage IVB}
[tube feeding]
[OxyNorm tube feeding]
[no sodium version of piperacillin + tazobactam]
[tube feeding]
It is possible to peel the Concor (bisoprolol 1.25mg) tablet in half or grind it for tube feeding.
[assessment]
A higher overshoot of bilirubin total than bilirubin direct might hint a sign that the patient’s red blood cells are breaking down at an unusual high rate.
During the first half hour of 14 o’clock 2023-01-04, there was a brief tachycardia moment with SBP exceeding 200mmHg. The vital signs are relatively stable now.
According to the Concor (bisoprolol 5mg/tab) package insert, the drug shold be swallowed with some liquid and not to be chewed. We are in the process of consulting the distributor for a response.
Atenolol can be used as an alternative antihypertensive agent (atenolol 50mg ~ bisoprolol 5mg) available under the brand name Urosin in the stock.
diphenhydramine 30mg + granisetron 1mg diphenhydramine 30mg diphenhydramine 30mg + granisetron 1mg[assessment]
[assessment]
The patient’s vital signs, laboratory data (2022-10-11), and the disease are in a generally stable state.
There is no issue with the active prescription. It is recommended that the last abdomen CT image be updated as it is dated 2022-04-13. A metastatic adenocarcinoma around the left 11th and 12th ribs (2022-05-03 pathology) might be surgically removed if it is symptomatic and feasible.
There was a generally normal lab result on 2022-09-12 and a relatively stable TPR and BP reading during this hospital stay. With the current regimen, the patient has tolerated it. In this case, the patient has only a muscle power of 4 or less, so some assistive devices might be beneficial.
{drug identification}
The drug imprinted “CTP A23” on the red-white capsule has not been found in available databases and remains unidentified.
[ABX use evaluation]
For most adults, the initial recommended antifungal treatment is an echinocandin (caspofungin, micafungin, or anidulafungin) given through the vein. Fluconazole, amphotericin B, and other antifungal medications may also be appropriate in certain situations.
[note]
[assessment]
During the past month, the patient’s liver and kidney functions have declined.
As the patient’s CrCl level is 17 mL/min according to the Cockcroft-Gault formula, it is recommended that the dosage of clarithromycin and amoxicillin be halved.
For patients with severely impaired kidney function, neither cisplatin nor carboplatin is recommended. Cetuximab is being administered as part of the patient’s treatment with CCRT.
In this patient, transthoracic echocardiography (2022-11-22) revealed dilated atria and RV, grade 1 LV diastolic dysfunction, mild AR, MR, and PR, moderate to severe TR, and pulmonary hypertension. Cardiopulmonary arrest or sudden death occurred in patients with squamous cell carcinoma of the head and neck receiving cetuximab with radiation therapy or a cetuximab product with platinum-based therapy and fluorouracil. It is recommended to closely monitor serum electrolytes, including magnesium, potassium, and calcium, during and after cetuximab administration.
{not completed}
{not completed}
[assessment]
{drug identification}
A request has been made for us to identify drugs for 10 items.
In total, 9 items have been identified as follows, with 1 item remaining unidentified.
These drugs will be sent back to ward by the in-hospital porter.
{not completed}
[assessment]
{Left breast cancer, pT2N1aM0, ER(+), PR(+), Her2(-), stage IIA s/p MRM on 2022-05-13}
[note]
[assessment]
{NSCLC, not completed}
[note]
this patient EGFR L858R mutation detected, ROS1 (IHC 1+, FISH undetected)
NCCN v5.2022
lab data
exam findings
consultation
radiotherapy
chemoimmunotherapy
The disease is characterized by L858R(+), exon19del(-), ALK(-), and PD-L1<1%. This patient has been treated with oral afatinib(2021-12 ~ 2022-07)/dacomitinib(2022-08 ~ undergoing) and IV ramu(2021-12 ~)/nivo(2022-01 ~)/ipi(2022-03 ~). It appears that the current regimen is still effective to keep the disease stable (2022-02 and 2022-06 CT: regression; 2022-09 CT: stationary).
The serum potassium level in 2022-10-17 was 2.9 mmol/L, and it might be beneficial to add potassium supplements.
The main concern for the patient and his caregiver might be pain management. For patients who require four or more doses of short-acting opioids consistently each day, addition of a long-acting opioid should be considered based on the total daily dose. A controlled-release oxycondone regimen has been prescribed to the patient since 2022-10-18.
In the event that the patient’s goals are not met (uncontrolled pain persists), then administer an opioid dose equivalent to 10%~20% of the total opioid taken in the previous 24 hours and reassess effectiveness and adverse effects (at 15 minutes if administered IV or at 60 minutes if administered PO).
{gastric cancer, T1a pN3a (6/32) cM0, pStage: IIB, s/p Op on 20220414}
[assessment]
The serum ALT level trended upward.
The use of oxaliplatin has been associated with an increase in ALT levels (incidence of 36% with monotherapy)
There is no need to adjust the dosage of the components in the current regimen of FOLFOX.
The addition of pyridostigmine as a self-carried item is recommended for the patient with myasthenia gravis since this medication has no known heavy interactions with the active prescription.
[assessment]
{Left ovarian cancer (clear cell carcinoma) post Debulking surgery on 2022/06/08, pT2aN0M0, FIGO stage IIA}
2022-12-03 CXR
2022-11-21, -11-17 CXR
2022-11-18 SONO - chest
2022-11-13 ECG
2022-10-20 CT - abdomen
2022-10-14 CXR
2022-07-29 Whole body PET scan
2022-07-28 CT - chest
2022-06-06 Patho - lymphnode biopsy
2022-06-06 CT - abdomen
2022-05-31 2D transthoracic echocardiography
2022-05-23 Patho - lymphnode biopsy
2022-05-23 Patho - breast biopsy (no need margin)
2022-05-17 SONO - breast
2022-03-09 CT - abdomen
2021-12-09 Whole body PET scan
2021-11-26 CT - abdomen
2021-11-18 SONO - abdomen
2021-08-27 CT - abdomen
2021-07-08 Gynecologic ultrasonography
2021-06-10 CT - abdomen
2021-05-27 SONO - abdomen
2021-03-10 CT - abdomen
2020-12-01 Patho - soft tissue tumor, extensive resection
2020-11-30 Patho - ovary (tumor)
2020-11-18 Whole body PET scan
2020-11-18 Gynecologic ultrasonography
2020-11-16 CT - abdomen
2020-10-28, -09-16, -09-15, -08-26, -08-25, -08-13 Body fluid cytology - ascites
2020-08-13 Patho - peritoneum biopsy
2020-08-07 Patho - ovary biopsy/wedge resection
2020-08-06 Gynecologic ultrasonography
2020-08-05 CT - abdomen
2020-08-05 SONO - abdomen
2020-05-16 Mammography
consultation
chemoimmunotherapy
{Pseudomyxoma peritonei (mucinous carcinoma peritonei), grade 1}
[drug identification]
Total 1 drug for identification.
The identified item is Vemlidy film-coated tablet containing tenofovir alafenamide 25mg which is indicated for the treatment of chronic hepatitis B virus (HBV) infection in adults with compensated liver disease.
The drug will be sent back to ward by the in-hospital porter.
{pancreatic cancer, endometrial cancer}
It should be noted that both serum creatinine and BUN increased 50% in the last two weeks (Cre 1.76 mg/dL 2022-11-30 <- 1.18 mg/dL 2022-11-16; BUN 33 mg/dL 2022-11-30 <- 20 mg/dL 2022-11-16), as well as bilirubin total exceeded 6 x ULN (6.95 mg/dL 2022-11-30).
2022-11-30 eGFR 31.2
2022-11-30 bilirubin total 6.95 mg/dL, ALT 442 U/L, AST 342 U/L
It is suggested to ensure that the patient’s kidney and liver function are in good condition prior to the chemotherapy.
[note]
[assessment]
{This 80-year-old man patient is a case of Diffuse large B-cell lymphoma, Non-GCB type, at the right maxillary gingiva and tuberosity, Ki-67 index >95%, Lugano stage II, IPI score: 1, Low risk group, PS:0}
[assessment]
{Esophageal cancer, cT2N2Mo stage III, Port-A insertion at left cephalic vein on 20220922, jejunostomy tube insertion at abdomen on 20220922}
[assessment]
{Protocol: Capsule suspension preparation and NG tube dispensing procedures for Xtandi (enzalutamide, 160mg dose)}
The following in-situ oral dosing syringe suspension preparation and NG tube dispensing procedures were identified as being facile and which essentially eliminate human exposure to capsule components:
Utensils: Tweezers, medical grade scissors, 2-3mL oral dosing syringe, 20mL oral dosing syringe, NG tube, and one 2-3 oz (60-90 mL) glass or plastic dosing container (e.g., beaker or med cup).
Materials: Ethanol, 95%, Deionized water, 4x40mg enzalutamide capsules
Please prepare two vials of 99.5% alcohol (drug code ‘CALCO01’), add one ml of purified water, take eight ml of the solution to dissolve one split capsule of 40 mg Xtandi, and tube feed this solution containing enzalutamide with prandial.
{Mesenchymal chondrosarcoma, high grade}
{expired}
[exam findings]
[MedRec]
[consultation]
[radiotherapy]
[chemoimmunotherapy]
Following standard brain RT and TMZ for multiple glioblastomas, the NCCN evidence blocks (2022-09-29 version 2.2002) recommends clinical trials, surgery for symptoms of large lesion, alternating electric field therapy, and palliative/best supportive care.
It has been reported in a review article that studies have been conducted using intra-arterial delivery of chemotherapeutics for the treatment of GBM, which may be considered as an optional last resort. (ref: A systematic review on intra-arterial cerebral infusions of chemotherapeutics in the treatment of glioblastoma multiforme: The state-of-the-art. Front Oncol. 2022;12:950167. Published 2022 Sep 23. doi:10.3389/fonc.2022.950167 )
In addition, there is also an article reported CAR T cell therapy and its potential to be integrated into the therapeutic paradigm for aggressive gliomas in the future. (ref: Clinical utility of CAR T cell therapy in brain tumors: Lessons learned from the past, current evidence and the future stakes [published online ahead of print, 2022 Oct 3]. Int Rev Immunol. 2022;1-19. doi:10.1080/08830185.2022.2125963 )
[assessment]
[note]
[assessment]
The GOLF regimen was introduced as a neoadjuvant treatment since late August 2022 with the aim of downstaging the tumor. The CT (2022-11-16) revealed that the adenocarcinoma of the duodenal bulb showed a mild increase in size and that the metastatic nodes displayed a decrease in size. There appears to be a greater likelihood that this will improve the feasibility of the surgery.
The decreased CA199 marker also served as a side evidence that the regimen is still effective.
Data available indicate stable vital signs, and there is no problem with the active prescription.
[assessment]
{drug identification}
requesting drug identification for 4 items.
the 3 items are identified as following while the other 1 item remains unknown.
The drug will be sent back to ward by the in-hospital porter.
{drug identification}
It was requested that four drugs be identified.
The items identified are as follows:
These drugs will be sent back to ward by an in-hospital porter.
[assessment]
{drug identification}
requesting drug identification for 6 items.
the 5 items are identified as following while the other 1 item remains unknown.
Indershin (indomethacin 25mg) Anrokin (chlorzoxazone 200mg) Leflo (levofloxacin 500mg) Ketofen (ketoprofen 50mg) Decan (dexamethasone 0.75mg)
The drugs were packaged as one dose in an opaque bag, which was opened irreversibly. The checked drugs will not be returned to the ward due to the possibility of contamination.
[assessment, not posted]
[assessment]
{gastric signet-ring cell carcinoma}
[assessment]
[assessment]
[assessment]
The trough value of vancomycin was reported on 2022-11-10 at 25.4 mcg/mL.
A blood draw time of “2022-11-10 00:00” has been recorded, this should be due to an invalid entry, please confirm that the concentration is actually a “trough”.
Redraw the value if it is not truly a “trough”.
In the event that the value is a real “trough”, then it is recommended to hold vancomycin and perform a renal function test.
[assessment]
[assessment]
{drug identification}
requesting drug identification for 1 item.
the item is identified as Serenal (oxazolam 10mg/cap).
the drug will be sent back to ward by an in-hospital porter.
[note]
{colon cancer}
[assessment]
{Extranodal NK/T-cell lymphoma, nasal type, Lugano stage II, PS: 0}
[assessment]
[assessment]
[assessment]
[assessment]
[assessment]
[note]
[assessment]
[assessment]
{breast cancer with brain mets}
This patient had received doxorubicin/cyclophosphamide (6, 2022-02-24 ~ 2022-06-07) and docetaxel (5, 2022-06-30 ~ 2022-09-01)
Brain MRI (2022-08-10) showed one solid mets increased in size and brain CT (2022-09-09) showed mild dilated intraventricular and extraventricular CSF spaces and two cystic lesions with fluid-fluid levels, about 20mm and 9.4mm in the left frontal lobe and about 44mm in the right parietotemporal lobe.
Pathology (2022-01-13) comfirmed breast cancer brain mets triple negative. Neither trastuzumab and its biosimilars/ADC(antibody drug conjugates) nor CDK4/6 inhibitors (e.g., ribociclib, palbociclib) might likely to show effective.
National Health Insurance covers PARP (poly ADP-ribose polymerase) inhibitors like olaparib and talazoparib for metastatic triple negative breast cancer with BRCA1/2 mutations since 2022-08-01.
For patients with triple-negative brain metastases from breast cancer (BCBM), two chemotherapy regimens seem to show specific CNS activity:
{ovarian cancer s/p debulking surgery}
[assessment]
2022-08
{DLBCL, diffuse large B-cell lymphoma}
[drug identification]
One drug for identification.
The drug will be sent back to ward by the in-hospital porter.
[drug identification]
Two drugs need identification.
the 2 identified items has been shown as following:
these drugs will be sent back to ward by an in-hospital porter.
{Endometrioid carcinoma, grade 2, of the uterine endometrium, AJCC Pathologic stage — pT3aN1aM1, stage IVB / FIGO stage IVB, s/p Laparoscopic gynecologic oncology staging surgery.}
lab data
exam findings
consultation
SOP
radiotherapy
chemoimmunotherapy
[assessment]
{Gastric adenocarcinoma of antrum with gastric outlet obstruction cT3N3bM1, stage IV, ECOG 1 status post laparoscoppic gastrojejunostomy and Port-A implantation on 2022-06-16}
[exam findings]
[chemoimmunotherapy]
2023-05-30 - etoposide 500mg/m2 1000mg NS 50mL 2hr D1-4
2022-06-02 - undergoing - Imbruvica (ibrutinib) 140mg/cap 4# QD
2022-04-11 - rituximab 375mg/m2 700mg 6hr + cisplatin 100mg/m2 190mg 24hr D2 + cytarabine 2000mg/m2 3900mg 3hr Q12H D3
2022-03-11 - rituximab 375mg/m2 730mg 8hr + cyclophosphamide 750mg/m2 1466mg 30min + doxorubicin 50mg/m2 97mg 30min + vincristine 1.4mg/m2 2mg 10min + prednisolone 60mg/m2 50mg BID PO D1-5 (R-CHOP)
2022-02-08 - rituximab 375mg/m2 700mg 6hr + cisplatin 100mg/m2 190mg 24hr D2 + cytarabine 2000mg/m2 3900mg 3hr Q12H D3
2022-01-04 - rituximab 375mg/m2 738mg 8hr + cyclophosphamide 750mg/m2 1470mg 30min + vincristine 1.4mg/m2 2mg 10min + prednisolone 60mg/m2 50mg BID PO D1-5
2021-12-08 - cytarabine 2000mg/m2 3900mg 3hr Q12H D3
2021-12-07 - rituximab 375mg/m2 700mg 6hr + cisplatin 100mg/m2 190mg 24hr D2 + cytarabine 2000mg/m2 3900mg 3hr Q12H D3
2021-11-16 - rituximab 375mg/m2 730mg 8hr + cyclophosphamide 750mg/m2 1466mg 30min + doxorubicin 50mg/m2 97mg 30min + vincristine 1.4mg/m2 2mg 10min + prednisolone 60mg/m2 50mg BID PO D1-5
2021-10-19 - rituximab 375mg/m2 738mg 8hr + cyclophosphamide 750mg/m2 1470mg 30min + vincristine 1.4mg/m2 2mg 10min + prednisolone 60mg/m2 30mg BID PO D1-5
This mantle cell lymphoma patient had been treated with R-CVP/R-CHOP/R-DHAP (until April 2022) and started receiving Bruton’s tyrosine kinase inhibitor ibrutinib in early June 2022 and achieved a partial response (2022-08-19 CT). As part of this hospitalization, images will be updated.
The combination of ibrutinib and venetoclax (this is not covered by National Health Insurance at present) has been shown to promote responses in patients with relapsed or refractory mentle cell lymphoma.
[assessment]
The patient has been diagnosed with ER(+) PR(+) HER2(-) breast cancer and has been treated with letrozole, an aromatase inhibitor, in combination with the CKD4/6 inhibitor, ribociclib (2021-09-22 ~ 2022-05-25).
She was also diagnosed with EGFR Exon19 deletion, PD-L1 TPS >= 50% lung adenocarcinoma, and is currently undergoing the TKI gefitinib (2021-09-23 ~ undergoing).
The use of atezolizumab might be an option for her subsequent treatment, as her lung cancer is also characterized by PD-L1 TPS >= 50%. (2021-09-23 S2021-11626)
Her bone mets were treated with zoltedronic acid (2022-01-12, 2022-02-09) and two falling accidents were noted in July 2022. In the event that zoltedronic acid is not well tolerated by the patient, Xgeva (denosumab 120mg SC) or romosozumab (currently not available at this hospital) might be an alternative.
[assessment]
Mosarla RC, Vaduganathan M, Qamar A, Moslehi J, Piazza G, Giugliano RP. Anticoagulation Strategies in Patients With Cancer: JACC Review Topic of the Week. J Am Coll Cardiol. 2019;73(11):1336-1349. doi:10.1016/j.jacc.2019.01.017
Johnstone C, Rich SE. Bleeding in cancer patients and its treatment: a review. Ann Palliat Med. 2018;7(2):265-273. doi:10.21037/apm.2017.11.01
There has been an observation of vaginal bleeding possibly caused by bevacizumab. A transfusion might be necessary if there is a significant loss of blood (which is not the case for this patient HGB 11.0 g/dL 2022-10-06).
Tranexamic acid has not been studied in advanced cancer, but it reduces mortality due to bleeding by approximately one-third. A reduction of approximately one-third in blood loss and transfusion requirements has been seen in meta analyses of its use in elective surgery as well.
No dose-response has been seen for tranexamic acid’s therapeutic effect, and the recommended dose is 10 mg/kg per dose given intravenously every 6-8 hours, with no benefit to doses above 1 gram.
Pancreatic cancer, adenocarcinoma, pT2N2M1, stage IV with liver mets with Paclitaxel and Gemcitabine Gastric cancer, adenocarcinoma, pT2N3aM0, stage IIIa Malignant neoplasm of unspecified site of left female breast
[assessment]
{HCC with lung & bone metastasis, suspected a large tumor at L5 vertebral body, R paravertebral / R perivertebral spaces}
[drug interaction]
Combination use of H2 antagonist (Famotidine) and PPI (Rabeprazole) might enhance gastric acid suppression, might also increase the potential risk of Clostridioides difficile infection. Ref:
{colon cancer}
[objective]
[not posted?]
2022-07-29 Whole body PET scan showed the FDG avid lesions in the T1 spine, in some right paratracheal and bilateral pulmonary hilar lymph nodes, in diffuse small focal areas in bilateral lung fields and in bilateral adrenal glands are either new or more evident.
In recent months, CEA lab data showed an increasing trend
F/S blood sugar level were 200 +- 20 mg/dL, body weight loss: 57kg <- 66kg (2022-06), empagliflozin 25mg QDPC or canagliflozin 100mg QDAC might be an optional add-on.
[visiting the patient]
[colon cancer]
[type 2 DM]
[dyslipidemia]
[assessment]
[felt fatigue in prior chemo]
visiting the patient at 09:47 on 2021-03-15, he is wide awake, this patient has not been administrated chemo regimen yet since this admission, in prior to the chemo course, consultations for C7 spinal segment and ONJ are arranged (based on his PET scan outcome).
he says he felt fatigue after chemo been started 2-3 days in the prior course.
HbA1c 8.3% and serum glucose (AC) 191mg/dL reported on 2021-01-14, no newer data available, could be followed up if necessary.
lab data
exam finding
consultation
(C5) Deltoid/Biceps 5 4 (C6) Wrist extensor 5 4 (C7) Triceps 5 4 (C8) Flex. dig. profundus 5 5 (T1) Hand intrinsics 5 5 (L2) Iliopsoas 0 0 (L3) Quadriceps 0 0 (L4) Tibialis ant. 0 0 (L5) Ext. hallu. longus 0 0 (S1) Gastrocnemus 0 0chemoimmunotherapy
Tagrisso - osimertinib 80mg/tab 1# QD PO
Cyramza - ramucirumab (NSCLC recommended dose in package insert: in combination with erlotinib, 10mg/kg Q2W IVD 60min)
Giotrif - afatinib 30mg/tab 1# QDAC PO
[assessment]
[drug identification]
requesting drug identification for 3 items.
the 2 items are identified as following while the other 1 item remains unknown.
these drugs will be sent back to ward by an in-hospital porter.
[drug identification]
Total 3 drugs for identification.
The 2 identified items has been shown as following while the other 1 items still remain unknown:
These drugs will be sent back to ward by the in-hospital porter.
s mouth was suctioned and a 4*8 gauze was placed at the patients
throat to prevent fluid from entering patient’s airway.[note]
Locally advanced squamous cell carcinoma of the head and neck ( https://www.uptodate.com/contents/locally-advanced-squamous-cell-carcinoma-of-the-head-and-neck-approaches-combining-chemotherapy-and-radiation-therapy )
[assessment]
chemotherapy induced oral ulcer is treated with Nincort Oral Gel (triamcinolone) and hepatitis B is surpressed using Baraclude (entecavir)
{Adenocarcinoma of splenic flexure colon with obstruction, and liver, lung, bone metastasis with carcinomatosis, cT3N2bM1c, stage IVC status post colostomy on 2021-10-06}
{vancomycin trough concentration}
There was a trough concentration of 9.4 mg/L recorded on 2022-10-03 in this patient treated with U-Vanco (vancomycin) 1000mg QW15 (based on his renal function) since 2022-09-25.
It appeared to be effective (CRP 15.84mg/dL 2022-10-03 <= 29.58mg/dL 2022-09-22) when vancomycin was used, however, it is recommended that serum vancomycin trough concentrations should always be kept above 10 mg/L to avoid resistance development. For a pathogen with an MIC of 1 mg/L, the minimum trough concentration would have to be at least 15 mg/L to generate the target AUC (Area under the curve): MIC of 400. (ref: Therapeutic monitoring of vancomycin in adult patients: a consensus review of the American Society of Health-System Pharmacists, the Infectious Diseases Society of America, and the Society Of Infectious Diseases Pharmacists. Clin Biochem Rev. 2010;31(1):21-24.)
Changing the current administration frequency from QW15 to QW135 is recommended to increase the concentration to at least 10 mg/L. Thank you!
BH 172, BW 109.2, BMI 36.9
past history
family history
lab data
exam finding
consultation
multiteam
surgical operation
radiotherapy
chemoimmunotherapy
{Primary peritoneal serous carcinoma (omentum, ileum, colon, appendix involvement), pT3cN0M0, FIGO stage IIIC s/p Optimal (R1) debulking surgery (TAH + BSO + BPLND + PALNS + OMENTECTOMY + CYTOLOGY) + CUSA + Right hemicolectomy (Terminal ileum + Appendix + ascending/transverse colon resection) on 20210111.}
[objective]
[assessment]
[assessment]
The blood pressure and blood sugar levels are within the normal range.
Human albumin 20g QD, furosemide 20mg QD, and spironolactone 25mg BID are currently being used to control patient edema.
Blood pressure and blood sugar are grossly in normal range.
Human albumin 20g QD, furosemide 20mg QD, spironolactone 25mg BID are currently applied to cope with the patients edema.
[assessment]
{multiple myeloma}
[assessment]
{adenocarcinoma of rectosigmoid, not completed}
[subjective]
[objective]
In the last three months, both AST and ALT have increased.
Oxaliplatin has been associated with hepatotoxicity, including elevated transaminases and alkaline phosphatases. Peliosis, nodular regenerative hyperplasia or sinusoidal abnormalities, perisinusoidal fibrosis, and veno-occlusive lesions have been detected on liver biopsy. Patients with portal hypertension or increased liver function tests, which cannot be attributed to liver metastases, should be evaluated for hepatic vascular disorders.
Hyperuricemia is noted (serum uric acid readings have been around 9mg/dL in 2022), allopurinol or febuxostat might be indicated.
Febuxostat differs from allopurinol in a number of ways:
Feburic (febuxostat 80mg/tab) 0.5# QD is recommended.
In the last half year, serum creatinine readings have been around 2 mg/dL, indicating altered kidney function. (170cm, 78kg -> eGFR 40mL/min/1.73m2, CrCl 40~45mL/min)
Fluconazole for candidiasis, prophylaxis - Hematologic malignancy patients or hematopoietic cell transplant (HCT) recipients who do not warrant mold-active prophylaxis: Oral 400 mg once daily. If the CrCl value is less than 50 mL/minute, the dosage is recommended to be reduced by 50%. The current dose is 300mg per day, which is less than 400mg, so no urgent adjustment is necessary.
As phenytoin is an inducer of CYP3A4 and P-glycoprotein and apxaban is metabolized predominantly by CYP3A4 and a P-gp substrate, the former may decrease the serum concentration of the latter.
Another direct oral anticoagulant Lixiana (edoxaban) undergoes minimal CYP metabolism (still an p-gp substrate) might be an alternative to Eliquis (apixaban). Edoxaban can be administered 30mg once daily for patients with CrCl 15 to 50 mL/minute.
As dexlansoprazole’s pharmacokinetics are not expected to be altered in patients with renal impairment, dose adjustment is not likely to be necessary.
[assessment]
Losartan might be held temperately due to a drop in blood pressure (2022-09-20 09:21 96/56mmHg).
Blood glucose levels were elevated (2022-09-20 06:40 236 mg/dL). If the reading remains high over the next two days, then antiglycemic interventions might be necessary.
[Chief Complaint] for chemotherapy
[Present Illness] This 46-year-old female patient had invasive carcinoma of no special type with focal micropapillay pattern of the right breast cancer, pT2N1M0, stage IIB, ER (postive, +++95%), RP (postive, +++80%), Her-2/Neu(equivocal, 2+), s/p MRM and ALND on 2017/11/30, post chemotherapy with AC 4 times since 106/12-107/03/13. Adjuvant chemotherapy with Taxotere on 108/04/04-6/6 and radiotheratpy.
On 2020/12/01, microinvasive carcinoma of the left breast, AJCC 8 th edition, Pathology stage: pT1miN0; Anatomic stage IA; Prognostic stage IA if cM0. Margins: Negative, Closest margin (7 mm from deep margin). ER (Ab): Positive (60%, moderate intensity), PR (Ab): Negative, HER-2/Neu (Ab): Positive (score= 3+), s/p left partial mastectomy and sentinel lymph node biopsy, radiotherapy (Radiotherapy with 5000cGy/25 ractions of the left breast, and 6000cGy/30 fractions of the left breast tumor bed (scar) area), and status during endocrine therapy.
Followed CT on 2022/1/28 which revealed Four Metastases on both hepatic lobes are highly suspected. Her-2 overexpressed liver metastases were confirmed after liver biopsy. Bone scan revealed a hot spot in the left humeral head, some faint hot spots in bilateral rib cage, upper T-spine, L2-3 spines, lower L-spine, sacrum, bilateral sternoclavicular junctions, upper portion of the sternum, shoulders, and knees in whole-body survey.
Then she recevied C1 Herceptin, Perjenta (840mg) for loading dose on 2022/2/14, Taxotere on 2022/2/15. C2 Herceptin, Perjenta on 2022/3/7 Taxotere on 2022/3/8. C3 Herceptin, Perjenta on 2022/3/28 Taxotere on 2022/3/29. C4 Herceptin and Perjenta on 2022/4/18,Taxotere on 2022/4/19. Followed CT of chest was performed on 5/2 revealed almost resolution of metastatic hepatic tumors (with a small residual lesion in S6) compared with abdominal CT on 1/28.minimal nonspecific RML inflammation and subtle small nodules inlower lobes of lungs, susggest f/u. Chemotherapy with C5 Herceptin + Perjenta (420mg) on 2022/5/9.Taxotere on 2022/5/10. C6 Herceptin + Perjenta (420mg) on 2022/5/30.Taxotere on 2022/5/31 C7 Herceptin + Perjenta (420mg) on 2022/6/20.Taxotere on 2022/6/21 C8 Herceptin + Perjenta (420mg) on 2022/7/11.Taxotere on 2022/7/12.
Followed up CT of chest on 2022/8/8 revealed 1.almost resolution of metastatic hepatic tumors (with a small residual low lesion in S6) compared with CT on 5/4 and 2.two small nodules in Rt lung still visualized, susggest f/u.
C9Herceptin + Perjenta (420mg) on 2022/8/29 and Taxotere on 2022/8/30
This time, she was admitted for chemotherapy on 2022/9/18.
{Olfactory Neuroblastoma}
[note]
[Angiotensin-Converting Enzyme Inhibitors / Angiotensin II Receptor Blockers]
[drug identification]
[not completed]
[assessment]
[tube feeding]
The capsule of Nexium (esomeprazole 40mg/tab) should be opened and the small granules poured into drinking water before tube feeding can begin.
[objective]
CEA lab data
According to CT scan impressions, the disease had responded to the current treatment (bevacizumab + FOLFIRI) introduced in early March 2021 and remains stable in the recent half year. However, CEA readings have also increased over the past 12 months.
Upon confirmation that the disease has acquired resistance, regorafenib might be considered as a subsequent treatment option.
The underlying condition HTN appears to be well controlled during this hospitalization. There are no updated hyperlipidemia lab results available for the past two years that could be ordered if clinically indicated.
[Rectal Cancer]
initial presentation
definite diagnosis
disease extent
treatment
effect and side effect
ongoing problem
Objective:
Assessment:
Suggestion:
Objective:
Assessment:
Suggestion:
Objective:
Assessment:
Suggestion:
[assessment]
Serum uric acid lab data
There is a history of gout in this patient, and his serum uric acid level is elevated. One option might be to prescribe Feburic (febuxostat 80mg) 0.5# QD for at least seven days.
Lab data: serum creatinine (2022-09-13 2.14 mg/dL <- 2022-09-01 1.20 mg/dL), BUN (2022-09-13 39 mg/dL <- 2022-09-01 23 mg/dL). The patient’s renal function is declining.
Male, age 58, 160cm, 45kg => BMI 17.6kg/m2, CrCl 24mL/min, eGFR 32~38mL/min/1.73m2
As this patient is mildly thin, an increase in intake is recommended in order to prevent malnutrition and build up some reserve for future treatment.
The use of carboplatin has been associated with renal adverse reactions, including decreased creatinine clearance (27%), and increased blood urea nitrogen (14% to 22%). In the next chemotherapy cycle, it might be an option to reduce the dose.
{not completed}
[assessment]
The patient’s blood pressure has been around 190(+-10)/90(+-10), despite taking the following antihypertensive agents as part of the active prescription:
Clonidine can be used for chronic hypertension as an alternative agent. It is not recommended for initial management but may be considered as additional therapy for resistant hypertension in patients who do not respond adequately to combination therapy with preferred agents (ACC/AHA [Whelton 2018]). We have in stock Catapres (clonidine 0.075mg) currently. Oral form immediate release: Initial 0.1 mg twice daily; increase dose in increments of 0.1 mg/day at weekly intervals based on response and tolerability; usual dose range: 0.2 to 0.6 mg/day in 2 divided doses. The manufacturer’s labeling includes a maximum daily dose of 2.4 mg; however, doses >0.6 mg/day are generally not used.
In an alternative attempt to lower the blood pressure, currently used Sevikar might also be replaced with Adapine (nifedipine 30mg) 1# BID and Micardis (telmisartan 80mg) 1# QD.
Minoxidil (not available in stock) can also act as an alternative adjunctive agent. It should be reserved for patients with resistant hypertension who do not respond adequately to an optimized 4-drug regimen, ideally consisting of a thiazide-like diuretic (eg, chlorthalidone) and a mineralocorticoid-receptor antagonist (eg, spironolactone). It can be used in combination with a beta-blocker to prevent reflex tachycardia. Fluid retention may occur and may require additional diuretic therapy (ACC/AHA [Whelton 2018]; Brook 2022). Oral form initial: 5 mg once daily, increase dose gradually in intervals of >= 3 days; usual effective dose: 10 to 40 mg/day in 1 to 3 divided doses; maximum dose: 100 mg/day in 1 to 3 divided doses. During therapy, if supine diastolic pressure is reduced <30 mm Hg, administer total daily dose once daily; if supine diastolic pressure is reduced >30 mm Hg, administer in divided doses (ACC/AHA [Whelton 2018]; manufacturer’s labeling).
{MDS, RAEB-1}
Alprazolam is metabolized by the enzyme CYP3A4 and the antifungal drugs itraconazole, ketoconazole, posaconazole, and voriconazole are strong inhibitors of this enzyme, which can increase the serum concentration of alprazolam.
Each member of the azole class exhibits a unique spectrum of activity, although fluconazole, itraconazole, voriconazole, posaconazole, and isavuconazole all demonstrate similar activity against most Candida species. (ref: Pappas PG, et al. Clinical Practice Guideline for the Management of Candidiasis: 2016 Update by the Infectious Diseases Society of America. Clin Infect Dis. 2016;62(4):e1-e50. doi:10.1093/cid/civ933 )
While fluconazole is a less strong (i.e. moderate) CYP3A4 inhibitor than voriconazole, it might be a suitable substitute for voriconazole if no other considerations are taken into account. Additionally, a change from 2# to 1# of alprazolam might also be considered.
On 2022-09-05, blood was drawn about one hour before the time of administration for cyclosporine TDM. It is recommended that blood be drawn within half an hour of the time of administration. As of the latest monitoring result, the level is 193.8 ng/mL, which is generally considered to be within the reasonable range (100 to 400 ng/mL). Based on changes in serum creatinine, renal function appears to be slowly declining (but still within normal range). It might take less time to achieve a concentration greater than 400ng/mL by consecutive daily doses of 200mg than it did in mid-July. A retest is recommended after three days to determine if the dose should be adjusted.
Time serial serum creatinine, cyclosporine trough concentration and cyclosporine daily dose log:
[recommended cyclosporine daily dose to maintain a stable and reasonable trough concentration]
[cyclosporine concentration]
[cyclosporine trough concentration]
[post-transplant immunization
[cyclosporine trough concentration]
As of 2022-07-14, the trough concentration of cyclosporine was 162 ng/mL, which is considered to be an acceptable level.
[Cyclosporine trough concentration follow-up]
[Cyclosporine (ciclosporin) concentration]
[cyclosporine trough concentration]
Dosage of ATG as part of the conditioning regimen in allogeneic PBSCT from matched sibling donors in patients with hematologic malignancies
[assessment, not posted]
[objective]
[assessment]
[assessment]
Patients with acute portal vein thrombosis should be started on low molecular weight heparin to achieve rapid anticoagulation, with a switch to an oral anticoagulant (warfarin or possibly a direct-acting oral anticoagulant [DOAC]) once the patient’s condition has stabilized and no invasive procedures are planned.
Patients with chronic portal vein thrombosis when treated with anticoagulation, enoxaparin is more often used rather than warfarin because of its shorter duration of action, less variability in anticoagulation, decreased need for monitoring, and decreased difficulty when managing patients around the time of liver transplantation. An alternative is to use an oral anticoagulant.
If warfarin is used, goal INR can be set as 2 to 3. (2022-08-03 INR 1.24)
Enoxaparin (in active prescription now) used for venous thromboembolism treatment in patients with active cancer:
Direct oral anticoagulant (DOAC) therapy is an alternative to enoxaparin or warfarin for treating chronic portal vein thrombosis.
Apixaban oral 10 mg twice daily for certain duration followed by 5 mg twice daily.
[assessment]
{Lung cancer at right lower lung, adenocarcinoma, with multiple brain metastasis, cT4N0M1b, stage IV, with mukltiple brain metastasis, PD-L1: TC < 1%, IC < 1%, TPS < 1 %, EGFR E19 deletion and T790M (+)}
[assessment]
[note]
{hypopharynx squamous cell carcinoma, cT3N1M0}
[assessment]
{Rt breast cancer with Rt axillary LNs, lungs, and liver metastases}
[objective]
{DLBCL stage IV}
[assessment]
[assessment]
{oropharyngeal cancer}
{Cholangiocarcinoma, pT4N0cM0, s/p S5 segmentectomy with lymph node dissection and cholecystectomy on 2020-01-13, with T11-12 metastasis and compression fracture s/p radiotherapy to T spine in 2020-04}
[assessment]
[note]
[assessment]
[assessment]
{Right upper lung adenocarcinoma, moderately differentiated with bone metastasis, stage IV}
[assessment]
[assessment]
{ovarian cancer, pT3aN0cM0, FIGO stage IIIA2}
{newly diagnosed with Endometrioid adenocarcinoma T1BN0M0 stage IB s/p Laparoscopic gynecologic oncology staging surgery}
[objective]
[assessment]
{lung adenocarcinoma and esophageal adenocarcinoma}
[Past History]
[note]
[assessment]
{prevent the patient from potential drug interaction: Dasatinib / Inhibitors of the Proton Pump (PPIs and PCABs)}
[assessment]
[assessment]
[note]
{colon cancer with liver mets}
[objective]
{Small Lymphocytic Lymphoma}
[objective]
{left pyriform sinus cancer, cT2N2bMx, stage IVA, brain mets}
{cervical cancer, adenocarcinoma, cT1bN1MB, FIGO stage IIIB}
[BFluid - the amount of electrolyte can be added]
A supplement to my explanation after answering the nurse’s call this morning about the compatibility of B Fluid with KCl.
{Thymic cancer, squamous cell carcinoma, cT4N2M1b, stage IVB, with malignant pleural effusion, bone and lung metastasis}
[note]
[visiting]
Dose adjustment recommendation for the scheduled PBSCT in this impaired renal function patient
[assessment]
{T-cell lymphoma with bone invasion, stage IV}
[note]
The disease should be subtype Peripheral T-cell lymphoma (PTCL), not otherwise specified (NOS)?
T-Cell Lymphomas NCCN EB Version 2.2022 - March 7, 2022, p13
Restage after 3-4 cycles with PET/CT (preferred) or C/A/P CT scan with contrast
Recommended Adult Immunization Schedule — United States, 2012 ( https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6104a9.htm )
[to be discussed]
[assessment]
{pancreatic neck adenocarcinoma,cT1cNXM1, stageIV, with retroperitoneal spread status post Roux-en-Y hepatico-jejunostomy and cholecystectomy}
[objective]
{DLBCL}
[assessment]
{Endometrium neuroendocrine carcinoma, pT2pN0M0, FIGO stage II s/p Staging surgery(ATH + BSO + omentectomy + LN dissection) on 2022/02/14}
[objective]
{Pancreatic adenocarcinoma, T4N1M0, stageIII}
[assessment]
{cholangiocarcinoma, recurrenct, liver and lung mets, s/p colon cancer}
[objective]
{right ovarian cancer, pT1c3N0 if cM0, FIGO IC3 s/p Op on 20200720}
[note]
{intra-hepatic cholangiocarcinoma with lung and right adrenal mets}
[assessment]
[assessment]
{valganciclovir not for herpes}
{pseudomyxoma peritonei}
[assessment]
{CNS DLBCL}
[objective]
[objective]
{alpha-fetoprotein-producing esophageal adenocarcinoma with liver metastasis, T4N2M1 stage IVB}
[memo]
[assessment]
[assessment]
{multiple myeloma}
{gastric cancer with colon mets s/p subtotal gastrectomy and partial T-colectomy}
[subjective]
[objective]
{high grade B-cell lymphoma}
[objective]
{follicular lymphoma}
[assessment]
{steroid conversion}
An approximate corticosteroid dosing conversion
[assessment]
{potential drug interactions}
{tachycardia}
[assessment]
[assessment]
700526699
{drug identification}
Total 14 drugs for identification.
The 10 identified items has been shown as following while the other 4 items still remain unknown:
These drugs will be sent back to ward by the in-hospital porter.
{upper GI bleeding}
[assessment]
{small bowel ileus}
[assessment]
[assessment]
{Vulvar Cancer}
[exam findings]
2023-05-11 CXR
2023-05-02 CXR
2023-04-26 MRA - brain
2023-04-07 CT - abdomen
2023-02-24 Tc-99m MDP bone scan with SPECT
2023-02-22 Skull PA + Lat.
2023-02-02 SONO - chest
2023-01-31 Mammography
2022-12-29 CT - abdomen
2023-03-19, -03-10, -02-05, -01-15, 2022-10-28, -10-25, -09-27, -09-22, -08-22, -06-24 CXR
2022-09-06 CT - abdomen
2022-08-16 Gynecologic ultrasonography
2022-07-05 Laryngoscopy
2022-06-16 Neurosonology
2022-06-16 Brainstem Auditory Evoked Potentials, BAEP
2022-06-15 MRI - brain
2022-06-02 CT - lung/mediastinum/pleura
2022-05-24 Gynecologic ultrasonography
2022-04-08 Chest XR
2022-03-14 Laryngoscopy
2022-03-11 Chest XR
2022-03-01 Gynecologic ultrasonography
2022-02-23 CT - lung/mediastinum/pleura
2022-01-17 Laryngoscopy
2022-01-03 Laryngoscopy
2021-11-06 CT - lung/mediastinum/pleura
2021-10-26 Bronchodilator test
2021-08-09 Tc-99m MDP whole body bone scan
2021-07-19 CT - lung/mediastinum/pleura
2021-04-09 Patho
2021-02-25 Patho
2021-01-29 MRA - Brain
2021-01-13 CT
2020-10-28 Tc-99m MDP whole body bone scan
2020-10-21 CT
2020-07-06 MRI - Brain
2020-07-03 CT
2019-09-18 Patho
2019-09-05 CT: multiple lung nodules, favor metastatic lesions.
2019-06-03 CT: uterine myoma is suspected.
2017-12-13 CT: a 3.0cm tumor at uterus.
2017-11-28 Patho
[consultation]
[surgical operation]
[chemoimmunotherapy]
2023-03-20 - irinotecan liposome 70mg/m2 95mg 1.5hr + leucovorin 400mg/m2 550mg 2hr + fluorouracil 2800mg/m2 3800mg 46hr
2023-02-22 - irinotecan liposome 70mg/m2 95mg 1.5hr + leucovorin 400mg/m2 550mg 2hr + fluorouracil 2800mg/m2 3800mg 46hr
2023-02-06 - irinotecan liposome 70mg/m2 95mg 1.5hr + leucovorin 400mg/m2 550mg 2hr + fluorouracil 2800mg/m2 3800mg 46hr
2023-01-15 - irinotecan liposome 70mg/m2 95mg 1.5hr + leucovorin 400mg/m2 550mg 2hr + fluorouracil 2800mg/m2 3880mg 46hr
2022-12-26 - irinotecan liposome 70mg/m2 97mg 1.5hr + leucovorin 400mg/m2 550mg 2hr + fluorouracil 2800mg/m2 3880mg 46hr
2022-11-25 - irinotecan liposome 70mg/m2 97mg 1.5hr + leucovorin 400mg/m2 550mg 2hr + fluorouracil 2800mg/m2 3880mg 46hr
2022-11-04 - irinotecan liposome 70mg/m2 97mg 1.5hr + leucovorin 400mg/m2 550mg 2hr + fluorouracil 2800mg/m2 3880mg 46hr
2022-10-13 - irinotecan liposome 70mg/m2 97mg 1.5hr + leucovorin 400mg/m2 550mg 2hr + fluorouracil 2800mg/m2 3880mg 46hr
2022-09-27 - irinotecan liposome 70mg/m2 97mg 1.5hr + leucovorin 400mg/m2 550mg 2hr + fluorouracil 2800mg/m2 3880mg 46hr
2022-09-05 - irinotecan liposome 70mg/m2 96mg 1.5hr + leucovorin 400mg/m2 550mg 2hr + fluorouracil 2800mg/m2 3850mg 46hr
2022-08-22 - irinotecan liposome 70mg/m2 96mg 1.5hr + leucovorin 400mg/m2 540mg 2hr + fluorouracil 2800mg/m2 3800mg 46hr
2022-07-29 - irinotecan liposome 70mg/m2 96mg 1.5hr + leucovorin 400mg/m2 540mg 2hr + fluorouracil 2800mg/m2 3800mg 46hr
2022-07-13 - irinotecan liposome 70mg/m2 96mg 1.5hr + leucovorin 400mg/m2 540mg 2hr + fluorouracil 2800mg/m2 3800mg 46hr
2022-06-28 - irinotecan liposome 70mg/m2 95mg 1.5hr + leucovorin 400mg/m2 540mg 2hr + fluorouracil 2800mg/m2 3800mg 46hr
2022-06-15 - irinotecan liposome 70mg/m2 95mg 1.5hr + leucovorin 400mg/m2 540mg 2hr + fluorouracil 2800mg/m2 3790mg 46hr
2022-05-30 - irinotecan liposome 70mg/m2 90mg 1.5hr + leucovorin 400mg/m2 530mg 2hr + fluorouracil 2800mg/m2 3700mg 46hr
2022-05-06 - irinotecan liposome 70mg/m2 90mg 1.5hr + leucovorin 400mg/m2 530mg 2hr + fluorouracil 2800mg/m2 3700mg 46hr
XXXX
2021-12-27 ~ undergoing - Onivyde (irinotecan liposome) + FL
2021-04-28 ~ 2021-12-03 - FOLFOX + Bevacizumab
2020-11-24 ~ 2021-04-06 - Nivolumab
2020-10-02 -
2020-07-23 ~ 2020-09-25 - Cisplatin + Vinorelbine, Vinorelbine, take turns alternately
2019-10 ~ 2019-12 - Cisplatin + Paclitaxel
[assessment]
[assessment]
[assessment]
[assessment]
[assessment]
[assessment]
Harnalidge (tamsulosin) 0.4mg PO QDAC should be replaced with Urief (silodosin) 8mg PO QD as a preferred alternative.
[assessment]
{mediastinum small cell carcinoma with pericardial effusion with SVC syndrome, stage IV}
[objective]
[assessment]
[assessment]
[objective]
[assessment]
[objective]
[assessment]
[objective]
[assessment]
[objective]
[assessment]
{ovarian clear cell carcinoma stage IA}
[objective]
[objective]
[assessment]
[objective]
[objective]
[assessment]
[objective]
This 43 years old female patient has the history of: 1) Chronic kidney disease for 10 years; 2) Ulcerative colitis with medical treatment for 20 years; 3) Fourth degree hemorrhoids status post hemorrhoidectomy on 20210623; 4) Left arteriovenous fistula on 20220124.
diagnosis
exam finding
lab data
surgical operation
[assessment]
This patient has CKD stage 5 adminitted on 2022-04-29
CKD stage 5, high Creatinine, high BUN, high phosphorus, low calcium, low bicarbonate normal CRP and WBC AV shunt
[objective]
{synchronous double (breast and colon) primary tumors s/p MRM s/p hemicolectomy}
[objective]
[assessment]
[objective]
{esophageal squamous cell carcinoma with liver and lung mets}
[objective]
[assessment]
[objective]
[assessment]
[objective]
[assessment]
{ovarian cancer}
[objective]
[tube feeding]
{Recurrent hepatocellular carcinoma with Lung and C-spine, T-spine and L-spine metastasis cT2N0M1 stage IV}
[objective]
[assessment]
{Acute myeloid leukemia}
[objective]
[Quinolones-Antacids Interactions]
objective
assessment
suggestion
[Interprofessional Practice Meeting and Family Meeting]
[mesna administration]
[objective]
Creatinine lab data: - 2022-01-10 1.25mg/dL - 2022-01-07 1.43mg/dL - 2022-01-03 0.93mg/dL
[assessment]
[suggestion]
[objective]
[reference]
[assessment]
{Left renal cell carcinoma with metastatic mediastinal lymphadenopathies and suspecious RUL lung metastasis, liver and bone metastases s/p chemotherapy and radiotherapy}
[objective]
{Recurrence nasopharyngeal carcinoma with skull base destruction and cranial nerve (V2, VI) invasion , liver metastasis and multiple lung metastases in progression.yT4N2M1,stageIVB}
[objective]
[assessment]
{rectal cancer with liver mets s/p LAR and liver partial resection}
[objective]
exam finding
lab data
surgical operation
chemoimmunotherapy
[assessment]
{Acute myeloblastic leukemia, not having achieved remission}
[objective]
[compatibility]
The combination of calcium gluconate, magnesium sulfate, and potassium chloride in 0.9% sodium chloride normal saline is compatible.
Lab data reported on 2022-01-10
Danol (Danazol) androgen is prescribed to pause menses to maintain RBC, HGB levels in the setting of chemotherapy.
{rectal cancer cT2N1bM0 stage IIIA}
[subjective]
[objective]
[initial presentation]
[definite diagnosis]
[disease extent]
[treatment & plan]
[effect & side effect]
[ongoing problem]
[assessment]
{hepatic failure, cirrhosis of liver, hepatorenal syndrome, esophageal varices, gastric varices, ascites, type 2 diabetes ellitus, hyperlipidemia, anemia}
[objective]
[assessment]
{ovary cancer s/p oophrocystectomy}
[objective]
[assessment]
[objective]
[assessment]
[objective]
[objective]
[assessment]
[objective]
[assessment]
{hypopharyngeal and supraglottic cancer, cT4bN2b cM0, stage IV with recurrent lung mets, progression of mets pulmonary lesions and mediastinal/hilar LAP}
[objective]
[assessment]
[objective]
[assessment]
{Malignant neoplasm of rectosigmoid junction, stage cT3N0M0, stage IIA}
[objective]
[objective]
[assessment]
{Peripheral T-Cell Lymphoma, PTCL, relapsed}
[objective]
[assessment]
{Nasopharyngenl Carcinoma - NPC, non-keratinizing carcinoma}
[objective]
[objective] ??
[objective]
[subjective]
[objective]
{rt breast ca (TNBC), cT2N0M0 stage IB}
[assessment]
[subjective]
[objective]
[assessment]
{Compatibility for both Tapimycin and KCl in Suntose}
{Panceratic carcinoma, cT1N1M1 (left neck subclavicle mets), stage IV}
[objective]
[assessment]
[objective]
[tube feeding]
The oral drugs in active medication including:
All the above drugs can be grinded and administrated via NG tube
[objective]
[assessment]
{myelodysplastic syndrome}
[objective]
[assessment]
[objective]
[lowering BP gently]
visiting the patient at around 16:45 on 2021-08-30, he did not complain of discomfort or unwellness these days, however he shared his experience of dizziness and fainting when SBP below 160mmHg since years ago. lowering blood pressure should be in a gentle way.
[assessment]
[suggestion]
[assessment]
[suggestion]
{SCC of tongue, cT4N1M0, s/p total glossectomy, right mandibular osteotomy, right marginal mandibulectomy, selective neck dissection, wide excision of malignant left lower gum SCC and marginal mandibulectomy, teeth extraction of #46, tracheotomy and free flap reconstruction}
[objective]
{gastric cancer, stage IIA, extra-capsular spread (ECS) positive}
[objective]
[assessment]
[objective]
[assessment]
[objective]
{Thalidomide/Dexamethasone Interaction}
Dexamethasone might enhance the dermatologic adverse effect and/or thrombogenic effect of Thalidomide.
Consider using venous thromboembolism prophylaxis in patients with multiple myeloma who are receiving both thalidomide and dexamethasone, particularly if the patient is newly diagnosed or has other risk factors for thromboembolism. Low-molecular-weight heparin or warfarin (at INR of 2.0-3.0) have been proposed as reasonable prophylactic agents. Regarding the potential dermatologic interaction between thalidomide and dexamethasone, monitor for any evidence of dermatologic events, particularly maculopapular or erythematous rash. If evident, discontinuation of drug therapy or dosage reduction may be required.
{possible drug interaction: Dasatinib / Histamine H2 Receptor Antagonists}
[objective]
[assessment]
[suggestion]
{marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue (MALT lymphoma)}
[objective]
COPD is listed as one of the diagnoses (but not in current problem list) in this hospitalization, however no corresponding medication prescribed yet.
Some bronchodilators such as beta agonists, antimuscarinic agents, or methylxanthines might be considered later after other acute symptoms mitigated.
{marginal zone lymphomas}
[objective]
[assessment]
This 92-year-old woman diagnosed by NTUH in 2021 Dec wtih advanced ascending colon cancer with lung, paraaortic LN, peritoneal carcinomatosis, cT4aN2bM1c, stage IVC.
Take into account of the patient’s age, intensive therapy might not be most appropriate, a vanilla regimen like FOLFOX could be a candidate for systematic treatment.
KRAS, NRAS, BRAF, HER2, MSI/MMR, NTRK fusion, dihydropyrimidine dehydrogenase test might be ordered optionally if related data from NTHU is not anticipated.
{lung cancer with bone and brain metastasis}
[lab data]
[exam findings] (not completed)
[immunochemotherapy]
[consultation]
{drug identification}
requesting drug identification for 6 items.
the 4 identified items has been shown as following while the other 2 items still remain unknown: - Megajohn - megestrol 160mg - Kentamin - thiamine 50mg, pyridoxine 50mg, cyanocobalamin 500mcg - Romicon-A - lysozyme 20mg, dextromethorphan 20mg, cresolsulfonate 90mg - Olmetec - olmesartan medoxomil 20mg
these drugs will be sent back to ward by an in-hospital porter.
[objective]
This is a patient diagnosed by TSGH with poorly differential gastric adenocarcinoma with carcinomatosis and metastatic lymphadenopathy and bone metastasis, cT4aN3aM1, stage IV, seeking for second opinion on 2022-01-21.
[Assessment]
Diagnosis: Splenic flexure colon obstruction and massive ascites suspected carcinomatosis status post T-loop colostomy on 2021-08-27.
2021-08-30 Patho - omentum tumor, extensive resection
2021-08-25 Patho - colorectal polyp
Medication
[objective]
[assessment, suggestion]
no drug allergy recorded in database.
CBC reported on 2022-01-18 showed items below normal ranges:
no liver or kidney dysfuncion shown in recent lab data.
the drugs prescribed at neurology OPD have been included in active medication, no issue found.
CBC reported on 2022-01-18 showed items below normal ranges:
no drug allergy recorded in database.
no liver or kidney dysfuncion shown in recent lab data based on AST, ALT, BUN, Creatinine, eGFR.
no issue found in active medication.
[objective]
Lab data - Free T4 - 2022-01-14 2.26ng/dL (normal 0.58~1.35) - 2021-10-05 1.94ng/dL - TSH - 2022-01-14 0.027uIU/mL (normal 0.38~5.33) - 2021-10-05 <0.005uIU/mL
PE - body weight - 2022-01-14 65kgw - 2022-01-09 68kgw
Medication - Eltroxin (levothyroxine 50mcg/tab) #1 BIDAC
[assessment]
[suggestion]
[hyponatremia, hypoosmolality]
objective
assessment
suggestion
[initial presentation]
[definite diagnosis & disease extent]
[plan & treatment]
[effect & side effect]
[ongoing problem]
{Diffuse Large B Cell Lymphoma}
[objective]
[assessment]
[suggestion]
CT and MRI on 2022-01-05 suggested possible malignant tumor in the right adrenal gland measuring 8.2 x 10 x 9 cm.
Chromogranin A 918ng/mL, ACTH < 5g/mL
lab data in early Jan 2022 did not backup hyperaldosteronism, hypercortisonlemia (i.e. both in normal range).
hypertenstion and/or tachycardia might have been mitigated by Concor (bisoprolol), higher readings of blood sugar (since mid Dec 2021) might have been reduced by Galvus Met (vildagliptin + metformin), these symptoms could be caused by neuroendocrine tumors.
[Objective]
Lab data reported on 2022-01-10 and some prescribed medication: - CRP 9.17mg/dL (normal <1), WBC 166*10^3/uL (normal 3.9~10.6) <= Tapimycin (Piperacillin + Tazobactam) - Blood Uric Acid 16.3mg/dL (normal 4.4~7.6) <= Fasturtec (Rasburicase) - Calcium 4.04 mmol/L (normal 2.2~2.65) <= Miacalcic (Calcitonin) - Magnesium 1.4mg/dL (normal 1.9~2.7) - Triglyceride (TG) 524mg/dL (normal <150), HDL-C 5mg/dL (normal >40) - Benz(BZO) intoxication positive (normal negative)
[Assessment/Suggestion]
[Objective]
[Assessment]
[Suggestion]
High Serum glucose 235mg/dL (2022-01-05), Lactic Acid 4.9mmol/L (2022-01-06), NAKO NO.5 500mL IVD BID and Saline 500mL IVD QD are prescribed.
High CRP 13.47mg/dL (2022-01-05), Procalcitonin (PCT) 8.37ng/mL (2022-01-06) suggest (probable bacterial) infectious process with systemic consequences. Tapimycin and Targocid are prescribed.
{drug identification}
requesting drug identification for 7 items.
the 3 identified items has been shown as following while the other 4 items still remain unknown:
Utapine F.C. Tablet (quetiapine fumarate 25mg) - bipolar disorder, schizophrenia
Zoloft F.C. Tablet (sertraline hydrochloride 50mg) - major depressive disorder (unipolar), obsessive-compulsive disorder, panic disorder, posttraumatic stress disorder, premenstrual dysphoric disorder, social anxiety disorder
Anxiedin Tablet (lorazepam 0.5mg) - anxiety
these drugs will be sent back to ward by the in-hospital porter.
{drug identification}
requesting drug identification for 13 items.
the 9 identified items are listed as following, however, the other 4 items still remain unknown:
these drugs will be sent back to ward by the in-hospital porter.
{potential drug interactions, vitamin supplement}
[objective]
[assessment]
[suggestion]
thanks and regards,
{dedifferentiated liposarcoma}
[tube feeding]
[objective]
[assessment]
[mesna compatibility for common solutions]
reply for the consultation from the ward, mesna is compatible with: - D5W (Dextrose 5% in water) - D5NS (Dextrose 5% in sodium chloride 0.9%) - D5W - 1/2 NS (Dextrose 5% in sodium chloride 0.45%) - NS (Normal saline (Sodium chloride 0.9%)) - Lactated Ringer’s Injection
[post IPP meeting following up]
busulfan inventory
preparation and administration precautions
underlying diseases
medical compliance
{hypoalbuminemia and proteinuria caused by UTI induced nephrotic syndrome?}
[tube feeding]
[objective]
[assessment]
[suggestion]
[tube feeding]
[iron supplement]
[drug interaction]
[objective]
[assessment]
[suggestion]
{ovary cancer s/p debulking surgery}
[history]
[initial presentation]
[definite diagnosis, disease extent]
[treatment]
[assessment]
{unresectable liver tumor}
[initial presentation]
[definite diagnosis, disease extent]
[underlying disease]
[assessment]
{colon cancer with suspected liver mets and peritoneal seeding}
[initial presentation]
[definite diagnosis, disease extent]
[assessment]
{hypophosphatemia, hypokalemia}
[objective]
[assessment]
[suggestion]
{UTI, hypoalbuminemia}
[objective]
[assessment, suggestion]
{esophageal scc with lung and stomach mets}
[definite diagnosis, disease extent]
[treatment]
[assessment]
{duplicated NSAIDs}
[objective]
[assessment]
[suggestion]
{potential drug interaction}
[objective]
[assessment]
[suggestion]
{breast cancer}
[initial presentation]
[definite diagnose, disease extent]
[treatment]
[assessment]
{tube feeding}
meitifen (diclofenac Na 75mg) PO QD which is controlled-release design might be changed to defram-k (diclofenac K 25mg) PO TID
{preparation and precaution - mephalan, post-IPP meeting following up}
patient family meeting and IPP meeting was held at 10:00 on 2021-08-24.
the schedule with regimen for PBSCT for the patient has been disclosed in the meeting.
melphalan dosing as a conditioning agent, 140mg/m2 or 200mg/m2 are more commonly seen. source:
the estimated total amount of melphalan used prior to the scheduled transplantation would be 8 vials.
preparation and administration precautions of mephalan:
damage of the oral mucosa together with profound myelo- and immunosuppression after transplantation may lead to local and systemic infections.
{sepsis and pancytopenia with underlying DLBCL}
[subjective]
[objective]
[assessment]
[suggestion]
{liver cancer with bone mets}
[initial presentation]
[definite diagnosis, disease extent, effect & side effect]
[treatment]
[assessment]
[suggestion]
{some preparation before tube feeding}
active medication is reviewed, all the oral drugs can be administered via NG tube.
acetin (acetylcysteine) and nexium (esomeprazole) should be dissolved in adequate drinking water prior to tube feeding.
{switch drug for tube feeding}
active medication has been reviewed, all the oral drugs can be administered via NG tube.
Harnalidge (tamsulosin) 0.4mg PO QDAC replaced by Urief (silodosin) 8mg PO QD is recommended.
{statin dose intensity and equivalency}
All the oral drugs in active medication have been reviewed and can be administered via NG tube.
Pravafen has not been found in active medication yet.
Pravafen should not be grinded or half-peeled. It contains fenofibrate 160mg and pravastatin 40mg, there is Lipanthyl Supra (fenofibrate 160mg) available in hospital, however pravastatin 40mg is out of stock for now.
Fluvastatin 80mg, lovastatin 80mg, simvastatin 20mg, pitavastatin 2mg, atorvastatin 10mg, rosuvastatin 5mg are alternatives for pravastatin 40mg. reference: http://www.mqic.org/pdf/UMHS_Statin_Dose_Intensity_and_Equivalency_Chart.pdf
{lung cancer with brain mets}
[initial presentation]
[definite diagnose, disease extent]
[treatment]
[assessment, suggestion]
{cecal cancer}
[initial presentation, definite diagnosis, disease extent]
[treatment]
[effect & side effect]
[ongoing problem]
[assessment]
{renal glucosuria?}
[initial presentation]
[definite diagnosis]
[disease extent]
[objective]
[assessment]
[suggestion]
{flumarin side effect monitoring}
[objective]
[assessment]
[suggestion]
{cancer workup}
[initial presentation]
[objective]
[definite diagnosis & staging workup]
[treatment]
[ongoing problem]
[assessment]
{post IPP meeting following up}
the schedule and regimen for PBSCT for the patient was disclosed in the meeting held on 2021-07-28 10:30.
the estimated total amount of busulfan used in the time table is 15 vials.
staff dispensing regimen during weekend are arranged.
preparation and administration precautions:
{mesna administration rate}
{colon cancer}
[initial presentation]
[definite diagnosis and disease extent]
[treatment]
[effect & side effect]
[ongoing problem]
{coadministration of Decan and Juluca}
[objective]
[assessment]
[suggestion]
{vaccination for splenectomised patients}
[objective]
[assessment]
[suggestion]
{suspected MDS}
[objective]
[assessment]
[suggestion]
{Rectal Cancer with UTI}
[objective]
[assessment]
[suggestion]
{potential interactions among lorazepam, olanzapine, morphine and labetalol}
[objective]
[assessment]
[suggestion]
{potential interaction when coadministering alprazolam, metoclopramide, olanzapine}
[objective]
the following items are listed in active medication: - alpraline (alprazolam, 0.5mg/tab) 1 tab PO HS - promeran (metoclopramide, 3.84mg/tab) 1 tab PO TIDAC - zyprexa zydis (olanzapine, 5mg/tab) 1 tab PO HS
[assessment]
[suggestion]
{potential interactions among alprazolam, olanzapine and zolpidem}
[objective]
[assessment]
[suggestion]
{post-IPP meeting following up}
patient family meeting and IPP meeting was held at 10:00 on 2021-07-06
the schedule with regimen for PBSCT for the patient has been disclosed in the meeting.
the estimated total amount of melphalan used in the time table is 6 vials.
preparation and administration precautions of mephalan:
[initial presentation]
[definite diagnosis]
2021-05-06 CT - abd - loculated fluid accumulation at uterus up to
9.7*7.1cm in largest dimension is found. - uterine abscess is considered
first. 2021-05-11 patho - ovary (tumor) - taiwan society of pathology
was consulted to diagnose: malignant spindle cell and epithelioid cell
neoplasm. - IHC: SALL4/BRG1/INI1(+), glypican/SATB2/cyclinD1( focal+);
SS18-SSX/OCT4/CD30/ETV4/MDM2/S100/NUT/MyoD1(-).
- molecular pathology: SS18(-)(poor quality); chr12p/q FISH: failed. -
comment: - while the majority of it was composed of relatively uniform
spindle cells, gland-like components were also notable, in conjunction
with the strong TLE1 immunostaining, justifying your original
consideration of synovial sarcoma. - the degree of nuclear atypia would
be somewhat too high for synovial sarcoma, and TLE1 expression is not
specific. both SS18-SSX IHC and SS18 FISH performed to exclude this
possibility. - given the gland-like structures which reminded yolk sac
tumor, SALL4 (multifocally positive) and glypican (weakly positive,
mainly in the gland-like structures) staining were performed and
somewhat supported the speculation, albeit neither convincing nor
specific enough. - attempt to pursue some molecular evidence of
isochromosome 12p with chr12p, chr12q, and chr12 centromere FISH failed.
- other possibilities including myoepithelial carcinoma were not
supported by the current immunostaining results. - the case was reviewed
by one senior GYN pathologist, one GU pathologist, and another soft
tissue pathologist, and no conclusion could be drawn. - while a germ
cell tumor with a component of yolk sac tumor and sarcomatoid
transformation could not be excluded, the overall pathologic and
clinical features would be atypical. - perhaps a genomewide study aiming
at copy number variation/LOH might help in this regard. - note: some of
the original immunostaining showed CK weak+, TLE1+, SMA f+, GFAP-.
2021-07-13 patho - ovary (tumor) - diagnosis: pelvic tumor, debulking
surgery - compatible with recurrent malignant neoplasm. - the sections
show a picture of spindle and epithelioid cell tumor characterized by
spindle, ovoid or epithelioid tumor cells with congestion, hemorrhage,
extensive necrosis, active mitoses, arranged in solid, focal fascicular
or focal gland-like or rossette-like pattern, compatible with tumor
recurrence.
[treatment]
{form virless (acyclovir) to famvir (famciclovir)}
[objective]
[assessment]
[suggestion]
{reported thrombotic microangiopathy with acyclovir}
[objective]
[assessment]
[suggestion]
{acyclovir to treat herpes virus infection in HBV active carrier}
[objective]
[accessment]
[suggestion]
{potential abx absorption problem}
[objective]
[accessment]
[suggestion]
{tube feeding}
all the oral drugs in active medication have been reviewed, the following two items can be peeled half but should not be grinded: - Curam (amoxicillin 875 mg, clavulanic acid 125 mg, tab) - film coated - Pentop (pentoxifylline 400mg, tab)
and the following item can not be peeled half or grinded: - Nexium (esomeprazole 40mg, tab)
the alternatives to above items, respectively, could be: - Soonmelt (amoxicillin 500mg, clavulanic acid 100mg, vial), if half-peeled Curam still too big to be fed. - there is no other drug containing same active ingredient with Pentop in the inventory, so please peel it (not too fine) to fit the tube. - Takepron (lansoprazole 30mg, tab) should not be grinded but can be peeled half.
{tube feeding}
all the oral drugs in active medication can be administrated via NG tube except following items which should not be grinded:
{tube feeding}
the oral drug takepron (lansoprazole, 30mg/tab) in active medication should not be grinded, while it can be peeled in half.
there is also an iv version takepron (lansoprazole, 30mg/vial) can be the alternative.
{Tube Feeding}
all the oral drugs in current medication can be administrated via NG tube.
actein effervescent (acetylcysteine) should not be grinded, please dissolve the drug in adequate amount of drinking water prior to tube feeding.
{post IPP meeting following up}
the schedule with regimen for PBSCT for the patient is disclosed in the meeting.
the estimated total amount of busulfan used in the time table is 15 vials.
people for dispensing regimen during weekend are also arranged.
preparation and administration precautions:
{drug identification}
requesting drug identification for 6 items.
the 4 identified items has been shown as following while the other 2 items still remain unknown: - sinemet (carbidopa 25mg, levodopa 100mg) - urief (silodosin 4mg) - rivotril (clonazepam 2mg) - through (sennoside 12mg)
these drugs will be sent back to ward by the in-hospital porter.
{problem list}
the active problems listed in the TPR sheet are shown as following:
[objective]
[assessment]
[suggestion]
{problem list}
active problems listed in 2021-05-08 14:14 DutyNote containing 2 items: - urinary tract infection - right lower lung pneumonia
[subj/obj]
[assessment]
[suggestion]
{colon cancer}
[subj/obj]
[assessment]
[suggestion]
{substance dependence}
[subj/obj]
[assessment]
[suggestion]
{returning to society}
[subj/obj]
[assessment]
[suggestion]
{colon cancer}
[initial presentation]
[definite diagnosis]
[disease extent & staging]
[treatment & plan]
[effect & side effect]
[ongoing problem]
{colon cancer}
[objective]
[assessment]
[suggest/plan]
{intrahepatic cholangiocarcinoma}
[initial presentaion]
[definite diagnosis]
[disease extent]
[treatment]
[effect and side effect]
[ongoing problem]
HCV, Cirrhosis, Child A - 2021-03-30 - HBsAg Nonreactive - Anti-HBc Reactive - Anti-HCV Reactive
hypertention, portal hypertension varicose vein GERD type 2 DM
2018-10 diarrhea on and off
2020-11-12 patho - colon biopsy
2020-11-12 CT, ABD: cT3N2aMia, stage IVA Re-evaluation on 12/14/2020 slightly decreased in tumor size.
2020 late Nov ~ 2021 early Jan CCRT, FU/LV 5040 cGy/28Fx in hope of receiving sphincter preserving surgery (Last RT on 1/5).
2021 Feb there after chemo FOLFOX
2021-02-18 CT, ABD: much regression of rectal cancer.
2021-03-10 Op Method: Abdominoperineal resection (APR)
Finding: 1. Tumor in rectum, cT3N2aM1a (enlarged nodes in left external
iliac chain) 2. End S colostomy is done over LLQ
3. One JV drain at pelvic area
rectal cancer, cT3N2aM1a s/p CCRT, was admitted for scheduled laparoscopic APR with permanent colostomy. - 2021-03-18 patho - abdomino-perineum resection - ypT3N1aMia stage IVA
2021-05-13 Self-Monitoring of Blood Glucose,SMBG QDAC
PatMRNo, PatID, PatName, PatBDate, PatGender
Brosym 4g Q12H
assumed 50kg body weight with Cockcroft-Gault formula, the estimated CrCl is 25mL/min, daily maximal dose is 4g (2g Q12H) according to package insert.
cefoperazone sulbactam
daily maximal 4g (2g Q12H)
Nexium (esomeprazole) should not be grinded, shifting to Takepron (lansoprazole) is recommended.
Actein should be dissolved in adequate drinking water prior to tube feeding.
thanks and regards,
all the oral drugs in active medication can be administrated via NG tube except Doxaben XL (doxazosin) which is release-controlled.
Urief (silodosin) is recommended as an alternative to switch Doxaben.
thanks and regards,
omeprazole lansoprazole pantoprazole rabeprazole
[objective]
{rectal cancer}
[initial presentation]
[definite diagnosis]
[disease extent & staging]
[treatment]
[effect & side effect]
[ongoing problem]
Decreased chemotherapy dose to 67 % for grade 3 diarrhea with blody weight loss. Decreased chemotherapy dose to 75 % for grade 2 diarrhea with blody weight loss.
701263241__999999__MNote
{colon cancer}
[objective]
2019-05-21 colonoscopy: one ulceative mass lesion with lumen stenosis over 15 cm from anal verge, patho - adenocarcinoma.
2019-06-12 laparoscopic anterior resection and partial cystectomy, findings:
2019-09-10 CT: recurrence over left pelvis, and omentum of LLQ.
stayed in USA for months, lost following up in Taiwan health care provider.
2021-01-04 CT abdomen: colon cancer s/p operation with peritoneal carcinomatosis with massive ascites, T0N0M1c, Stage IVC.
2021-04-06 CT abdomen, pelvis:
2021-04-16 ascites tapping: 3075cc clear yellowish ascites was drained.
2021-04-20 cyto, ascites: smears show clusters of pleomorphic tumor cells. the morphology is consistent with metastatic adenocarcinoma.
CEA
CA199
CA125
regimen
[assessment]
701265877
{Colon cancer}
[subj/obj]
(transverse) colon cancer with liver metastases, cT4aN1aM1c, stage IV s/p LPS right extended and hemicolectomy on 2020-03-26 and seedings over omentum found.
chemo (palliative) from 2020-04-27 with FOLFOXIRI (ox: self-paid; iri: insurance covered) with bevacizumab.
chest echography on 2021-02-23 showed right thorax pleural effusion s/p drainage of 600 cc.
CXR on 2021-03-09 showed right thorax small pleural effusion.
CEA:
CA199:
for 3 consecutive weeks then 1 week off as a cycle
Oral target therapy with Cobimetinib 20mg 1# po QD (self-carried) (for 3 consecutive weeks then 1 week off as a cycle) from 2021/02/24~2021/0314. Oral target therapy with Dabrafenib 75mg 2# po Q12H (self-carried) (for 3 consecutive weeks then 1 week off as a cycle) from 2021/02/24. Chemotherapy with biweekly Erbitux(500mg)/Campto(100mg) (C1D1) on 2021/02/24, (C1D15) on 2021/03/10, (C2D1) on 2021/03/24, (C2D15) on 2021/04/07. Oral target therapy with Mekinisc 2mg 1# po QDAC(self-paid) from 2021/03/15 (for 3 consecutive weeks then 1 week off as a cycle). Therefore, the treatment would be cetuximab plus irinotecan(C1D15) and dabrafenib and MEK inhiitor, under the recognition of T-colon cancer with metastases to liver, peritoneum and pleura, and with B-Raf mutation. This time, she was admitted for Chemotherapy with biweekly Erbitux(500mg)/Campto(100mg) (C3D1) on 2021/4/22.
Oral target therapy with Dabrafenib(Tafinlar) 75mg 1# po BID(self-carried) from 2021/02/24 Oral target therapy with Mekinisc 2mg 1# po QDAC(self pay) from 2021/03/15. Chemotherapy with biweekly Erbitux(500mg)/Campto(100mg) (C3D1) from on 2021/04/23
{colon cancer}
[objective]
[assessment]
[suggestion]
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[initial presentation]
[definite diagnosis]
[disease extent]
[Summary]
This 67-year-old woman has the history of 1: Solitary pulmonary nodule, r/o malignancy 2: Type 2 DM Parapneumonic effusion, right This time, she has suffered from dyspnea for weeks. Since the symptom exacerbation recent days. She was then brought to our ER for further help. At ER, rapid screeing of COVID19 revealed negative finding. CXR showed bilateral consolidation and pleural effusions, cardiomegaly. Lab exam revealed elevated CRP. Under the impression of suspect COVID19 pnuemonia, right lung mass and bilateral pleural effusion, the patient was admitted for further care on 20210629.
Bilateral pneumonia Bilateral pleural effusion r/o COVID -19 infection
=> Abx with Brosym => Oxygen supplement => Oral radi-K => Diuretic for bilateral plerual effusion => Transfer to CM ward if PCR negative
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This 67-year-old woman has the history of 1: Solitary pulmonary nodule, r/o malignancy 2: Type 2 DM 3: Parapneumonic effusion, right.Under the impression of suspect COVID19 pnuemonia, right lung mass and bilateral pleural effusion, the patient was admitted for further care on 20210629.After admission. antiboitc with Brosym for pneumonia and fiuretic for bilateral plerual effusion were given. RT-PCR of COVID-19 revealed negative finding. The patient might transfer to chest ward for further management on 2021/06/29.
After CM ward, she has been orthopnea and dyspnea was noted, well explained present condition and treatment plan to the patient and her husband, emergency arrange cardiac echo and chest echo for right lung mass, pericardial effusion and bilateral pleural effusion for evaluation. Cardiac echo and chest echo was done and smoothly on 06/30, cardiac echo showed moderate amount pericardial effusion, No RV compression sign, No tamponade, No pericardial constriction at present, recommended to consult with cardiac surgery for P.P. window. Chest echo report showed Left side massive amount of pleural effusion, s/p thoracentesis, yield 1000cc, serosanguos fluid. Right side minimal amount of pleural effusion. She was transferre to SICU for intensive care on 6/30. We consult CVS for moderate amount pericardial effusion and P.P window surgery(Pericardiac effusion:1350cc) on 7/01. All operation procedure smoothly and return SICU for postoperation care. Weaning ventilaotr with etubated on 7/01. Under hemodynamic stable and she will be transfer to ward for care.
After transfered to Chest ward on 7/3, Tumor marker showed elevated CA-125, CA199, 7/6 CT guide biopsy was done and patho showed adenocarcinoma with TFF-1(-), abdomen CT showed ascites and multiple soft tissue nodules in the omentum, pending cytology, and lobulated pleura thickening at right anterior basl CP angle that may be tumor seeding or primary pleura tumor. brain MRI showed No brain nodule or metastasis, EGD+colonscopy was done on 7/12 showed gastric adenocarcinoma, bone scan was done on 7/13, whole body PET was done on 7/15 revealed prominent glucose hypermetabolic lesion in the right lateral aspect of the pharyngeal wall, we will consult ENT for assessment, she was transfered to hema ward on 7/16 for further assessment and management.
[objective]
The patient suffered from SOB, air hunger, cold sweat, and the cold of four limbs, the 12 lead EKG: sinus tachycardia, the heart rate from 139bpm to 58bpm, the blood oxygen drop, changed the oxygen support with NRM O2 fll, the SpO2 97%, then we can’t measure blood pressure, and the patient consciousness become drowsy and the blood oxygen drop again, under the NRM O2 full. The VS Xia talks about the patient’s condition to the family, so gave the endo inserting, on levophed and Dopamin high dose will be transferred to MICU.